Success Cycles , or from Kick the CANS to Yes, We CAN!

1. Success Cycles, or from Kick the CANSto Yes, We CAN! Nathaniel Israel, PhD May 16, 2011 SFDPH OQM for CYF-SOC

2. 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.

3. Thank-yous • Sai-Ling Chan-Sew • John Lyons • Parent (and now Youth!) Partners • Stephanie Romney • Deborah Sherwood • Emily Gerber • ….and all of our system partners who make this work meaningful for families

4. Implementation Development: CANS • Lyons (2008) states that implementation of the CANS proceeds through distinct stages in how people perceive and use it. They are as: • a Form • a Tool • the Work itself • Only in the second and third stages do families and clinicians see clear benefits in using the CANS to collaboratively identify, set and achieve goals • Implementation must focus on scaling-up use while also increasing people’s ability to use the CANS as a collaborative communication and decision-support framework

5. Going to Scale • Success with a pilot does not mean that system-level roll out will be successful • The complexity becomes geometric when scaling up • Paradox: may have a larger total investment with worse outcomes

6. Paradox Explained • Unless clinicians get to the point at which they use the CANS as a natural part of their clinical practice, the CANS will seem like just another form....in which case you’ve invested a lot of time and effort to get pushback • Similar process with becoming proficient in nearly any endeavor: you start with frustration and failure, and then gradually over time you become effortlessly proficient (figure skating (triple axle, triple lutz, football: perfect spiral)

7. CANS Implementation Dynamics • Form  Pushback • “I thought we were trying to reduce the paperwork in the system” • Tool  Trade Time Invested for a Clear Return • “It’s more work, but I can see why we do it” • the Work  Part of Routine / Clinical Flow • “It’s just the way I think now”

8. Getting Stuck at Step 1 • I already ask about these things; why isn’t narrative good enough? • Stories and experiences lost if they’re not tracked; no chance to have larger effect • How do we know what should be a client, program, system priority? • You can’t ask families about these things without alienating them • Families: it’s not what you ask, but the way you ask it which matters

9. Getting to Step 3 Fundamental shift for many clinicians • Realize that Training for Collaborative Decision-Making is often distinct from our professional training / identity • Requires a humility that is rarely taught or valued: taught to interpret and be experts • Requires us to be willing to be taught and led by our families: to share power • Requires new emotional experience and new skills

10. Can this wait? • Nearly half of all clients either are poorly-engaged or prematurely drop out • 25% of clients get worse while in treatment • Leading cause of clinician burnout • Families’ response to Assessment-as-Usual • “I’m so mad because I’ve just had a CANS done, and none of this happened. (Working collaboratively) is how I wanted it to happen.”

11. Listening to Learn 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 using the CANS in the care process can maximize engagement, family-direction

12. What we Heard 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

13. What were we missing? • Already created forms: • Embedded CANS into existing narrative assessment • Created a Treatment Plan that linked the CANS items and Treatment Plan Goals • Feedback system that showed progress over time • Clinicians were doing these things without family engagement / involvement

14. Training Format Parents’ goal: to change clinicians’ behavior to be more in line with collaborative practice • Curriculum 3 half-day trainings, co-led by parent. Two role-plays by each personeach day • At the following training date we discuss at least one new behavior which clinicians tried

15. Skill Example 1:Explain Treatment Process on First Contact • “Conversation Starting Point” for Confidentiality • Collaborative Scheduling Form • Content of First Sessions • Supports / Needs for Attending Sessions • Immediate Needs / Tips / Behaviors to Try

16. Skill Example 2. Sensitively assess the seriousness of behavioral / emotional concern • Asking parent about Child / Youth Substance Use • Typical response • “The quickest way to hear that there is no substance use is to directly ask if there is substance use”

17. Skill Example • Alternate method: • Start with strengths of parent “Many parents are concerned about the role models their children are exposed to” • Ask about situations which are not personal “Do you have any concern that your youth sees people in your neighborhood who are using substances?” • Move successively closer to personal information (school and peers, home)

18. Skill Examples by Cultural Group • Many similarities across groups • All stated that all questions associated with completing the CANS can be asked • At times, persons of different cultural groups emphasized different concerns • African American families particularly concerned about issues of Confidentiality • Discussions of sexual behavior particularly sensitive for our Cantonese parents

19. Care Empowerment Training • Outputs: • Three trainings to date with different programs; parent partner is co-trainer • Outcomes: • Trainee perception of training relevance • Parent and Youth satisfaction with clinician skills (currently being collected) • Client outcomes (variation by parent-rated skill)

20. Top Secret Preliminary Findings

21. Relevance and Usefulness

22. Summary: Parent Training This training is consistent with the goal of more fully empowering families in their children’s behavioral healthcare It allows us to move collaboration upstream in the care process, replacing practices which have led to clinician burnout and client dropout It provides specific, family-directed practices which we can teach and track for how they relate to engaging families and achieving clients’ goals

23. Rollout: Next Stage • Engaging youth in similar process • Scaling-up: Step 1 • Required training for all incoming interns and their supervisors • Using multi-method feedback on change in care practice (parent and youth survey, ongoing focus groups) • Your thoughts and feedback

24. Resources and Feedback • Scripts and resources available online at: http://successfulmentalhealthsystems.wikispaces.com • E-mail me at: nathaniel.israel@sfdph.org or (if there’s the issue of attachments) ndisrael@gmail.com