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Individualizing Care Within a Managed Care Context. 2006 Training Institutes July 2006 Institute #4 Ray Lederman D.O ., CPSA-Tucson Frank Rider , AZ Division of Behavioral Health Services Toni Tramontana , ValueOptions – Maricopa County Robin Trush , System of Care Veteran – Maricopa County. - PowerPoint PPT Presentation
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Individualizing Care Within a Managed Care Context
2006 Training InstitutesJuly 2006
Institute 4
Ray Lederman DO CPSA-Tucson
Frank Rider AZ Division of Behavioral Health Services
Toni Tramontana ValueOptions ndash Maricopa County
Robin Trush System of Care Veteran ndash Maricopa County
Institute 4 Overview
Transforming Managed Care The Arizona System
Structure What Happened Why We Did What We Did
How to Operationalize Results to Date
Change vs Transformation
Definition of ChangeChanger (Old French for ldquochangerdquo) to bend or turn like a tree or vine searching for the sun
Definition of TransformationTransformare (Latin for transform) ldquoto change shaperdquo
Why is Transformation Necessary
Family Dissatisfaction
Fragmented Care
Poor Outcomes
FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES
ARIZONA STATE GOVERNMENT
(Appropriations)
ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS)
REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)
SUBCONTRACTED PROVIDERS
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
(SAMHSA)
CENTER FOR MEDICARE AND MEDICAID SERVICES
(CMS)
$
$
$
$
$
$
Arizonarsquos Behavioral Health SystemAHCCCS
(State Medicaid Agency)
Arizona Department of Health ServicesBehavioral Health Services
Pascua Yaqui Tribal RBHA
Community Partnership of Southern Arizona
(CPSA)
ValueOptions
Northern Arizona RBHA (NARBHA)
Acute Care Health Plans
Cenpatico BH
Subcontracted Providers
Subcontracted Providers
Subcontracted Providers
Long Term Care Program Contractors
(eg DDD)
Gila River Tribal RBHA
Subcontracted Providers
Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS
TOTALFY 2006 FUNDS
Childrenrsquos
Percent ofChildrenrsquos $
MedicaidTitle XIX(674 federal)
$760640800
$269079100
8868SCHIPTitle XXI(77185 federal)
$15130000
$15130000
499Federal Grants
$44631300
$10981200
362
County Funds (Maricopa Pima)
$39161500
$1803000
059State Appropriations
$117516600
$6444600
212
Other
$3778200
0
000
Total Funding
$980858400
$303438500
10000
Behavioral Health Services in Arizona
Statewide enrollment 141393 (children and adults)Statewide children lt18 39020
ValueOptions enrollment 73845
ValueOptions children lt18 20041
Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Institute 4 Overview
Transforming Managed Care The Arizona System
Structure What Happened Why We Did What We Did
How to Operationalize Results to Date
Change vs Transformation
Definition of ChangeChanger (Old French for ldquochangerdquo) to bend or turn like a tree or vine searching for the sun
Definition of TransformationTransformare (Latin for transform) ldquoto change shaperdquo
Why is Transformation Necessary
Family Dissatisfaction
Fragmented Care
Poor Outcomes
FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES
ARIZONA STATE GOVERNMENT
(Appropriations)
ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS)
REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)
SUBCONTRACTED PROVIDERS
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
(SAMHSA)
CENTER FOR MEDICARE AND MEDICAID SERVICES
(CMS)
$
$
$
$
$
$
Arizonarsquos Behavioral Health SystemAHCCCS
(State Medicaid Agency)
Arizona Department of Health ServicesBehavioral Health Services
Pascua Yaqui Tribal RBHA
Community Partnership of Southern Arizona
(CPSA)
ValueOptions
Northern Arizona RBHA (NARBHA)
Acute Care Health Plans
Cenpatico BH
Subcontracted Providers
Subcontracted Providers
Subcontracted Providers
Long Term Care Program Contractors
(eg DDD)
Gila River Tribal RBHA
Subcontracted Providers
Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS
TOTALFY 2006 FUNDS
Childrenrsquos
Percent ofChildrenrsquos $
MedicaidTitle XIX(674 federal)
$760640800
$269079100
8868SCHIPTitle XXI(77185 federal)
$15130000
$15130000
499Federal Grants
$44631300
$10981200
362
County Funds (Maricopa Pima)
$39161500
$1803000
059State Appropriations
$117516600
$6444600
212
Other
$3778200
0
000
Total Funding
$980858400
$303438500
10000
Behavioral Health Services in Arizona
Statewide enrollment 141393 (children and adults)Statewide children lt18 39020
ValueOptions enrollment 73845
ValueOptions children lt18 20041
Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Change vs Transformation
Definition of ChangeChanger (Old French for ldquochangerdquo) to bend or turn like a tree or vine searching for the sun
Definition of TransformationTransformare (Latin for transform) ldquoto change shaperdquo
Why is Transformation Necessary
Family Dissatisfaction
Fragmented Care
Poor Outcomes
FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES
ARIZONA STATE GOVERNMENT
(Appropriations)
ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS)
REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)
SUBCONTRACTED PROVIDERS
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
(SAMHSA)
CENTER FOR MEDICARE AND MEDICAID SERVICES
(CMS)
$
$
$
$
$
$
Arizonarsquos Behavioral Health SystemAHCCCS
(State Medicaid Agency)
Arizona Department of Health ServicesBehavioral Health Services
Pascua Yaqui Tribal RBHA
Community Partnership of Southern Arizona
(CPSA)
ValueOptions
Northern Arizona RBHA (NARBHA)
Acute Care Health Plans
Cenpatico BH
Subcontracted Providers
Subcontracted Providers
Subcontracted Providers
Long Term Care Program Contractors
(eg DDD)
Gila River Tribal RBHA
Subcontracted Providers
Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS
TOTALFY 2006 FUNDS
Childrenrsquos
Percent ofChildrenrsquos $
MedicaidTitle XIX(674 federal)
$760640800
$269079100
8868SCHIPTitle XXI(77185 federal)
$15130000
$15130000
499Federal Grants
$44631300
$10981200
362
County Funds (Maricopa Pima)
$39161500
$1803000
059State Appropriations
$117516600
$6444600
212
Other
$3778200
0
000
Total Funding
$980858400
$303438500
10000
Behavioral Health Services in Arizona
Statewide enrollment 141393 (children and adults)Statewide children lt18 39020
ValueOptions enrollment 73845
ValueOptions children lt18 20041
Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Why is Transformation Necessary
Family Dissatisfaction
Fragmented Care
Poor Outcomes
FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES
ARIZONA STATE GOVERNMENT
(Appropriations)
ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS)
REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)
SUBCONTRACTED PROVIDERS
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
(SAMHSA)
CENTER FOR MEDICARE AND MEDICAID SERVICES
(CMS)
$
$
$
$
$
$
Arizonarsquos Behavioral Health SystemAHCCCS
(State Medicaid Agency)
Arizona Department of Health ServicesBehavioral Health Services
Pascua Yaqui Tribal RBHA
Community Partnership of Southern Arizona
(CPSA)
ValueOptions
Northern Arizona RBHA (NARBHA)
Acute Care Health Plans
Cenpatico BH
Subcontracted Providers
Subcontracted Providers
Subcontracted Providers
Long Term Care Program Contractors
(eg DDD)
Gila River Tribal RBHA
Subcontracted Providers
Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS
TOTALFY 2006 FUNDS
Childrenrsquos
Percent ofChildrenrsquos $
MedicaidTitle XIX(674 federal)
$760640800
$269079100
8868SCHIPTitle XXI(77185 federal)
$15130000
$15130000
499Federal Grants
$44631300
$10981200
362
County Funds (Maricopa Pima)
$39161500
$1803000
059State Appropriations
$117516600
$6444600
212
Other
$3778200
0
000
Total Funding
$980858400
$303438500
10000
Behavioral Health Services in Arizona
Statewide enrollment 141393 (children and adults)Statewide children lt18 39020
ValueOptions enrollment 73845
ValueOptions children lt18 20041
Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES
ARIZONA STATE GOVERNMENT
(Appropriations)
ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS)
REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)
SUBCONTRACTED PROVIDERS
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
(SAMHSA)
CENTER FOR MEDICARE AND MEDICAID SERVICES
(CMS)
$
$
$
$
$
$
Arizonarsquos Behavioral Health SystemAHCCCS
(State Medicaid Agency)
Arizona Department of Health ServicesBehavioral Health Services
Pascua Yaqui Tribal RBHA
Community Partnership of Southern Arizona
(CPSA)
ValueOptions
Northern Arizona RBHA (NARBHA)
Acute Care Health Plans
Cenpatico BH
Subcontracted Providers
Subcontracted Providers
Subcontracted Providers
Long Term Care Program Contractors
(eg DDD)
Gila River Tribal RBHA
Subcontracted Providers
Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS
TOTALFY 2006 FUNDS
Childrenrsquos
Percent ofChildrenrsquos $
MedicaidTitle XIX(674 federal)
$760640800
$269079100
8868SCHIPTitle XXI(77185 federal)
$15130000
$15130000
499Federal Grants
$44631300
$10981200
362
County Funds (Maricopa Pima)
$39161500
$1803000
059State Appropriations
$117516600
$6444600
212
Other
$3778200
0
000
Total Funding
$980858400
$303438500
10000
Behavioral Health Services in Arizona
Statewide enrollment 141393 (children and adults)Statewide children lt18 39020
ValueOptions enrollment 73845
ValueOptions children lt18 20041
Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Arizonarsquos Behavioral Health SystemAHCCCS
(State Medicaid Agency)
Arizona Department of Health ServicesBehavioral Health Services
Pascua Yaqui Tribal RBHA
Community Partnership of Southern Arizona
(CPSA)
ValueOptions
Northern Arizona RBHA (NARBHA)
Acute Care Health Plans
Cenpatico BH
Subcontracted Providers
Subcontracted Providers
Subcontracted Providers
Long Term Care Program Contractors
(eg DDD)
Gila River Tribal RBHA
Subcontracted Providers
Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS
TOTALFY 2006 FUNDS
Childrenrsquos
Percent ofChildrenrsquos $
MedicaidTitle XIX(674 federal)
$760640800
$269079100
8868SCHIPTitle XXI(77185 federal)
$15130000
$15130000
499Federal Grants
$44631300
$10981200
362
County Funds (Maricopa Pima)
$39161500
$1803000
059State Appropriations
$117516600
$6444600
212
Other
$3778200
0
000
Total Funding
$980858400
$303438500
10000
Behavioral Health Services in Arizona
Statewide enrollment 141393 (children and adults)Statewide children lt18 39020
ValueOptions enrollment 73845
ValueOptions children lt18 20041
Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS
TOTALFY 2006 FUNDS
Childrenrsquos
Percent ofChildrenrsquos $
MedicaidTitle XIX(674 federal)
$760640800
$269079100
8868SCHIPTitle XXI(77185 federal)
$15130000
$15130000
499Federal Grants
$44631300
$10981200
362
County Funds (Maricopa Pima)
$39161500
$1803000
059State Appropriations
$117516600
$6444600
212
Other
$3778200
0
000
Total Funding
$980858400
$303438500
10000
Behavioral Health Services in Arizona
Statewide enrollment 141393 (children and adults)Statewide children lt18 39020
ValueOptions enrollment 73845
ValueOptions children lt18 20041
Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Behavioral Health Services in Arizona
Statewide enrollment 141393 (children and adults)Statewide children lt18 39020
ValueOptions enrollment 73845
ValueOptions children lt18 20041
Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
13287
7270
20122
10530
19225
10217
27580
14316
28488
14725
34924
18892
34368
17199
39020
20041
0
5000
10000
15000
20000
25000
30000
35000
40000
2000 2002 2004 2006
Arizona T-19
Maricopa T-19
Arizona Total
Maricopa Total
Rapidly Expanding EnrollmentJune 2000 - June 2006
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Impetus for Change
Community Initiatives
Legislation ndash Executive Order
System of Care Grant Program
Litigation
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Arizonarsquos Impetus JK Litigation
Governor ADHS
JK Settlement was groundbreaking First to overhaul a state mental health system that operated on
a managed care basis
httpwwwazdhsgovbhsjkfinalengpdf
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
JK 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 Termination of Agreement July 1 2007
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned 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 childrsquos and familyrsquos cultural heritagerdquo
JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
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 Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Child and Family Team (CFT) Process
Based on the Wraparound ApproachService 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)
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family
Process for Practice
bullCFT Formation Engagement
bullClinical Expertise Crisis Planning
bullService Authorization Consensus
bullStrength and Needs-Based Planning Single Points of Contact
bullPartnerships Cultural Competence
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
How to Change Organizational Thinking
Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
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 ldquoLearning Withrdquo
William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Changing Organizational Thinking
Language as an Organizing Framework
ldquoLanguage creates a cultureLanguage preserves a culturerdquo
Bea Salazar Four Directions Consulting Riverton WY
Example Mental Retardation
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Changing Organizational Thinking
ParentProfessional Partnerships
Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels
State Local and Individual
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Changing Organizational Thinking
Philosophical Alignment of Child-Serving Systems
Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Partnerships
ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Changing Organizational Thinking
Leadership
Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Changing Organizational Thinking
Early Innovators
Urgency Ownership Commitment to Action Not for the Weak of Heart
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Arizonarsquos Early Innovators 300 Kids Project
ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo 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
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Going to Statewide Scale Practice Transformation
On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide
implementation
1312003 ldquo300 Kidsrdquo (12 of 24110 total children)
1312005 58 with CFTs (n = 1895 of 32924)
5312006 3304 with CFTs (n = 11284 of 34368)
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Structure Process Outcomes
Structural Changes Covered Services Funding
Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents
Outcomes Quality Management
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Structural Changes Necessary
Arizonarsquos Covered BH Services
Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or
Quantity v Quality
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Structural Changes NecessaryArizonarsquos Covered BH Services
Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation
Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Structural Changes Necessary
Funding
Variations in State Capitation Rates
Maximizing State Funding
Provider Contracting Methodology
Sustainability of Effort
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Process Changes Necessary
Training and Coaching
Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Process Changes Necessary
Consultants
State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Process Changes Necessary
Professional Roles
Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
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
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Process Changes Necessary
Quality Management Systems
ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs
System of Care Values Cost and Resources
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Quality Management Structure
Examples
EnrollmentPenetration (Latino youth 0-3 yo) 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
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Quality Management Structure
JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses
ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Quality Management Structure
Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH
Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)
ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH
Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Quality Management Process
CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo
1 Has a trusting relationship been established with the family (engagement)
2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family
3 Has an Individualized Service Plan been created that meets the needs of the child and family
4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Quality Management ProcessCFT Process Measurement
Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417
Statewide 5325 [n = 486]
Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53
Statewide 6045 [n = 418]
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Improved Processes Improved Outcomes
EXAMPLEs
Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased
Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)
Project MATCH (Pima County AZ)
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
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 OrsquoDay amp Rider (2004)
High Fidelity CFT Low Fidelity CFT
WFI Scores 853 536
CAFAS 132 128
CBCL Total 89 78
Level of Residential Placement
17 17
Number of Moves in Previous Six Months
22 16
Family Resource Scale 35 31
ldquoIt Even Works in Arizonahelliprdquo
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
8090
100110120130140150160
Inta
ke
6 M
onths
12 M
onths
Time Interval
Av
era
ge
CA
FA
S S
co
re
Overall HF CFT LF CFT
50
60
70
80
90
100
Inta
ke
6 M
onths
12 M
onths
Time IntervalA
vera
ge
CB
CL
To
tal
Sco
re
Overall LF CFTHF CFT
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 OrsquoDay amp Rider (2004)
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
10152025303540
Time Period
Av
era
ge
Re
sid
en
tia
l Le
ve
l
Overall Low Fidelity
High Fidelity
00
05
10
15
20
25
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e M
ove
s p
er S
ix M
on
ths
Overall Low Fidelity
High Fidelity
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 OrsquoDay amp Rider (2004)
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
reOverall
2022242628303234363840
Inta
ke
6 M
onths
12 M
onths
Ave
rag
e F
RS
Sco
re
Low Fidelity High Fidelity
Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos 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 OrsquoDay amp Rider (2004)
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Promising Data about Arizona Children
Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)
Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Promising Data about Arizona Children
(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)
(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692)
Ages 12-17 114 higher with CFT (662)
ADHS CIS (0506) N = 31690 childrenfamilies
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Promising Data aboutArizonarsquos Children
Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)
Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)
ADHS CIS (0506) N = 31690 childrenfamilies
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled children in this age range
00
100
200
300
400
500
600
700
800
900
CFT
No CFT
CFT 751 711 760 583 667 877
No CFT 596 593 658 524 545 817
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17
From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf
for all enrolled youth in this age range
00
200
400
600
800
1000
CFT
No CFT
CFT 712 685 713 565 648 811
No CFT 550 571 608 481 539 774
Increased Stability
Increased Safety
Avoids Deliquency
Prep for Adulthood
Success in School
Lives with Family
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Family Perceptions of Outcomes
Practice Based Evidence
Practical approach Strength based Positive risk taking Gives voice to both families being
served and to frontline workers
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Next Steps in Arizona
Building Capacity and Competency
Children 0-3 yo and Their Families
Substance Abuse
Positive Behavior Support
Child Welfare (See Institute 24)
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Next Steps in Arizona
Natural Supports
Youth Voice
Adult System Transformation
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
Questions
Thank you for your attention
Toni Robin Frank and Dr Ray
