Disparities: From the Chasm to the CANS

1. Disparities:From the Chasm to the CANS May 18, 2011

2. Acknowledgements 1. Larke Huang, PhD for this opportunity 2. Bob Friedman, PhD and Gary Blau, PhD for suggesting we should discuss what’s happening in SF when we are in DC 3. Grant program for the opportunity to build an infrastructure to bring to life the values of collaboration and family-driven, youth-guided care

3. Disclaimer The work presented here by an employee of the San Francisco Department of Public Health does not imply endorsement by, or the official position of, the San Francisco Department of Public Health.

4. Structure • Practice model we’re using in SF to identify and address disparities • Specific examples of identified disparities • Practices we’re using to address these disparities • Strategies we’re using to prevent these disparities from recurring • Lessons we’ve learned • Opportunities for learning

5. 1. Practice Model

6. Equality Action Cycle

7. A Learning Loop to End Disparities 1. Identify area of disparity 2. Identify the most critical behavioral health issues of children and youth in these contexts 3. Engage with families and youth regarding how to engage them, identify their needs and strengths, and provide appropriate supports 4. Pilot-test appropriate supports for children and youth at these interchanges 5. Identify the behavioral health and ultimate outcomes of these interventions 6. Collect process data around how outcomes were achieved 7. Modify training and supervision based on specific feedback re: process Repeat.

8. 2. Examples of Identified Disparities

9. A Common Start: Billing Data • Looked for areas of disparity per our billing data a. Found disparities in behavioral health service receipt in two types of restrictive care settings: i. Services in Juvenile Justice settings ii. Services in Residential Care settings

10. Disparities • Behavioral Health Services in J.J. settings • System average: 7.6% • African American youth: 12.3% • Latino youth: 10.2% • Behavioral Health Services in Residential / C.W. settings • System average: 5.7% • African American youth: 8.2% • Latino youth: 3.3%

11. Disparities: Early Successes • Services in Crisis settings • System average: 4.8% • African American youth: 4.1% • Latino youth: 4.3% • Services in Hospital settings • System average: 1.1% • African American youth: 0.2% • Latino youth: 0.4%

12. Keys to Early Successes • Multi-cultural staff to promote cultural match • Use of a decision support tool to monitor decision-making / prevent emergence of disparities • Childhood Severity of Psychiatric Illness • Illinois effects: use eliminates ethnic disparities in inappropriate hospitalization • Renamed “Crisis Assessment Tool” • San Francisco effects: promotes clinically appropriate placement decisions for crisis cases

13. SF CAT • Basic Decision Support Algorithm:

14. SF CAT • Disposition: • Looked at disposition for 278 consecutive clients • Appropriate decisions 97% of time

15. Lessons from Successes • Importance of using decision support tool to reduce bias in placement decision-making • Importance of having clear, well-defined care protocol • Importance of time-limited service with clearly defined goals for the time in care

16. 3. Practices to Address Identified Disparities

17. Addressing Remaining Disparities • Identify type and intensity of supports needed for children and youth at these interchanges (via CANS) • Provide appropriate supports to address specific needs of children and youth in these contexts • Create feedback loop around outcomes and practices a. Juvenile Justice Example 1. AIIM Higher Initiative b. Child Welfare Example 1. Foster Care Mental Health Program

18. Needs: Youth at Juvenile Justice Level of Care Needed Percent Number Outpatient 2% 1 Intensive Community 59% 33 Very Intensive 39% 22

19. JJ-involved: Critical Needs

20. JJ-involved: Critical Needs

21. MST – Addressing Critical Needs

22. Needs: Children in Child Welfare Level of Care Needed Percent Number Subclinical 24% 60 Outpatient 31% 77 Intensive Community 26% 65 Very Intensive 16% 39 Assessment for Hosptlztn. 4% 10

23. CW-involved: Critical Needs

24. CW-involved: Critical Needs

25. TVS – Addressing Critical Needs

26. Addressing Needs: Summary • Children and youth in high-risk settings have different levels and types of needs • Once these needs are known, these children and youth must be routed to the appropriate supports • When appropriate supports are provided, care is effective in substantially reducing behavioral and emotional needs and can reduce the risk for re-entry to multiple systems (per MST) • These supports, however, do not have an explicit family feedback component re: preferred care

27. 4. Strategies to Prevent Disparities

28. From Intervention to Prevention • By the time families have reached these multi-system interchanges, they often have very complex needs • These needs may have been prevented or ameliorated by earlier intervention • Two initiatives are designed to improve care before families become deeply involved in multiple systems (more effective, earlier)

29. CANS: Care Empowerment Training • Conducted over 20 focus groups with parents / caregivers of African-American, Latino and Chinese children and youth • Latino and Cantonese groups conducted in native language by native speakers • Designed to better understand how care process can maximize engagement, family-direction

30. Why do this? • How would more effective clinical collaboration prevent escalation in behavioral health needs among multi-stressed families? • Better needs assessment: Collaboration essential to creating a common understanding of needs • Parent experience, “If you don’t pinpoint what you need, you don’t get help” but, “in crisis you know you need some help but you don’t always know what [help] you need” • More targeted, effective treatment: Having a clear, shared goal leads to more focused treatment designed to facilitate rapid improvement • Parent experience, “My kids are in eternal therapy hell”

31. CANS: Care Empowerment Training Parents taught us that Clinicians should be able to: • Explain the Treatment Process on first contact • Sensitively assess the seriousness of behavioral / emotional concerns • Clarify the function of identified behavioral / emotional concerns • Collaboratively review the assessment for accuracy • Create clear, achievable goals in the family’s words • Review and problem-solve progress towards goal achievement

32. CANS: Care Empowerment Training • Outputs: • Three trainings to date with different programs; parent partner is co-trainer • Outcomes: • Supervisors rate this training as highly relevant, more useful than expert-driven training • Parent satisfaction with clinician skills (currently being collected) • Client outcomes (looking by variation in parent-rated skill)

33. PTI: Effective Parenting Interventions • Designed to promote dissemination of effective parenting practices • Target population is families identified for Differential Response • Uses Evidence Based Treatments to maximize likelihood of positive outcomes • High-fidelity adaptation for use across cultural and linguistic groups

34. PTI: Implementation Cycle • Based on NIRN model of implementation (Fixsen, Blase, Naoom, Wallace 2009) • Heavily emphasizes pre-training assessment of fit between program and practice • Every group includes assessment of parent and child outcomes via validated measures • After each group completes, a focus group is run with parents to better understand what worked and did not work in terms of fit with parent needs and program model

35. Initial Implementation Framework Staff Performance Evaluation Consultation & Coaching Decision Support Data Systems Integrated & Compensatory Facilitative Administrative Supports Preservice Training Recruitment And Selection Systems Interventions Fixsen, Blase, Naoom, & Wallace, 2009

36. Does Implementation Matter? • There is a pernicious rumor that implementing an Evidence Based Practice means that you’ll now have more effective and even cost-effective care • This often glosses over the fact that poor implementation practices can make any intervention costly and ineffective • On the next slide, the two sites on the left had minimal planning and follow-through re: high-fidelity implementation of the intervention. Those on the right had upfront-planning and high-fidelity implementation.

37. PTI: High Cost of Poor Implementation No Readiness Assessment With Readiness Assessment

38. High-Fidelity Implementation • So can high-fidelity implementation reduce disparities in clinical outcomes? • Because people come into care with different levels of need, what we would need to see is that the slope of change is equal across all groups.

39. PTI: Implementation effects by Ethnicity

40. The Answer • The previous slide clearly demonstrates that, across linguistic and cultural groups, you can get the same effects of care • To get these outcomes requires a continuous feedback process with rapid communication about implementation successes and needs, followed by rapid action to address needs and celebrate successes

41. Summary: Upstream Interventions • These interventions are consistent with the goal of more fully empowering families in their children’s behavioral healthcare • They allow us to move upstream in the care process, correcting a ‘fail-up’ care system • They provide specific, family-driven roadmaps for how to approach clinical practice and how to implement and modify clinical practices

42. 5. Lessons We’ve Learned

43. Review: Lessons from the Loop • Communities can identify important sources of disparity, even by starting with looking at their billing data • We must listen to families to provide targeted, effective care for children and youth with complex needs • Targeted interventions for very high-risk groups can reduce behavioral health needs and the risk of multi-system re-entry • Families can also provide important information about improving collaboration at all levels of care, and the fidelity and usefulness of community-delivered EBPs • This information must be part of a communication loop which feeds back to tell us what we’re doing and how well we’re reducing disparities and promoting equality

44. Next Steps • Fully integrating parent feedback for interventions provided to high-risk groups (MST, TVS interventions) • Learning from current variation in outcomes at program / clinician level (data-driven PBE initiative) • Collaborating with local family advocacy groups to create Parent-to-Parent and Youth-to-Youth tools for directing a child / youth’s behavioral health care • Linking collaboratively identified needs to specific appropriate treatment practices • Identifying how our process can be useful to other systems and communities

45. Implications for Creating Equality Now • 1. We must make children’s stories count • This requires moving from a reflexive, crisis-driven system to a thoughtful, data-driven system integrating ethnographic and quantitative data • 2. Creating equality requires shifting our mindset • Stakeholders need exposure to peers who use a learning / action cycle to target and implement practice changes for improving equality • 3. A responsive data infrastructure supports new decisions • Feedback on actions must happen at the speed that decisions are made; there is incredible duplication of effort as localities build custom data systems with limited feedback capability • 4. Ongoing training allows continuing change to occur • Expert assistance needs to be routinely available as clinicians change their practices and as contexts themselves change • 5. High-quality care closes the equality chasm • For high-quality care to become routine, incentives must align to support the learning process and reward equalization of health outcomes

46. 6. New Opportunities for Learning