The HOMEBUILDERS® Model: What We Have Learned Over the Last Thirty Years

1. The HOMEBUILDERS® Model: What We Have Learned Over the Last Thirty Years Shelley Leavitt, Ph.D. Institute for Family Development

2. What is Homebuilders? Homebuilders is an intensive in-home family treatment program designed to keep children and families safe and prevent the unnecessary out of home placement of children, and to safely reunify children and families.

3. Homebuilders Program Philosophy It is best for children to be raised in their own families whenever possible.

4. Applications of the Homebuilders Model • Placement Prevention • Reunification • Adoption and Long-Term Foster Care Stabilization

5. Program Model Intervention Activities Program Structure Values and Beliefs

6. Homebuilders Program Structure: Values Based Orientation The Homebuilders model is based on a clearly articulated set of values and beliefs, which guides program design and staff behavior.

7. HomebuildersValues and Beliefs • Safety is our highest priority • We cannot predict which situations are most amenable to change • A crisis is an opportunity to change • It is our job to motivate clients and instill hope • Family members are our partners • We can make life worse for families

8. HomebuildersValues and Beliefs (Continued) • Children can be brought up in different kinds of families • People are doing the best they can • It is our basic job to empower family members • It is helpful for us and the family to think of ourselves as “personal scientists” • It is important to minimize barriers to service

9. Homebuilders Program Components Program Components are designed to minimize barriers to service: • Focus on a Specific Target Population-Children at imminent risk of out of home placement and children in placement who are at the point of reunification • Immediate Availability and Response toReferrals- Referrals are accepted 24 hours a day, 7 days a week. The Homebuilders therapist meets with the family as soon as possible and no later than 24 hours after the referral is received

10. Homebuilders Program Components • Services Provided in the Natural Environment –Primarily in the home and in the community where the problems occur • Intensive Services – Average of 8-10 face to face hours/week • Brevity of Services – Average of 4-6 weeks; extensions and booster sessions • Low Caseload – Average 2 families

11. Homebuilders Program Components • Twenty-Four Hour a Day Availability to Clients – Primary therapist and supervisor available to families 24/7 • Single Therapist Operating within a Team - Assures consistency, enhances engagement, minimizes duplication of services and increases accountability

12. Homebuilders Program Components • Supervision and Consultation – Supervisor available 24/7; weekly individual and group consultation • Accountability – Goal oriented interventions, evaluations of outcomes, family and referring worker feedback • Ongoing Training and Quality Enhancement (QUEST)

13. Homebuilders Intervention Activity: Promoting Safety Throughout the intervention, the therapist assesses child, family, therapist and community safety and develops safety plans, structures the environment and uses clinical strategies to promote safety.

14. Homebuilders Intervention Activity: Individually Tailored Services Services and teaching strategies are “tailored” to the family’s needs, goals, values, learning styles and specific circumstances. The therapist flexibly schedules sessions with family members, based on the family’s schedule and situation.

15. Homebuilders Intervention Activity: Engagement and Motivation Enhancement The therapist develops and maintains a positive, collegial working relationship with family members and assumes responsibility for motivating the family.

16. Homebuilders Intervention Activity: Comprehensive Assessment The therapist conducts a behaviorally specific, interactive, ongoing, and holistic assessment, which includes information on family strengths, problems, needs, values, skills and potential barriers to goal attainment.

17. Homebuilders Intervention Activity: Goal Setting and Service Planning The therapist collaborates with family members and referring workers in developing behaviorally specific, attainable intervention goals and service/treatment plans.

18. Homebuilders Intervention Activity: Cognitive and Behavioral Approach The Homebuilders therapist utilizes research-based cognitive and behavioral intervention strategies to facilitate behavior change in children, youth and parents/caregivers.

19. Homebuilders Intervention Activity: Teaching and Skill Development The therapist uses a variety of teaching methods including role playing, coaching, direct teaching, work sheets, audio/visual materials and homework to help family members learn and use new skills.

20. Homebuilders Intervention Activity: Provision of Concrete Services The therapist advocates for and provides concrete good and services including transportation, food, clothing and accessing funds to pay for rent, utilities etc, which are directly related to achieving the family’s goals.

21. Homebuilders Intervention Activity: Collaboration and Advocacy The therapist collaborates and advocates with formal and informal community resources and systems while teaching family members to advocate and access services and supports for themselves.

22. Homebuilders Intervention Activity: Transition and Service Closure Prior to the conclusion of services, the therapist and family assess goal attainment, plan for the maintenance of progress, and collaborate with the referring worker and other organizations and resources to address ongoing service needs.

23. Development and Expansion of the Homebuilders Model • 1974 – Program began in Washington state • 1978 – 1994 Homebuilders expanded statewide in Washington • 1987 – 1990 Homebuildersproject in New York City

24. Dissemination of the Homebuilders Model National Dissemination begins 1988 • New Jersey – First state to attempt replication • Disseminated in 40 states including: Alabama, Indiana, Kentucky, Louisiana, Michigan, Missouri, New York, Pennsylvania and Washington

25. International Dissemination of the Homebuilders Model International Dissemination – Since 1990 • Australia, Belgium (Flanders), Bermuda, Canada, Finland, Germany, The Netherlands, Portugal and the United Kingdom.

26. Changes/Enhancements to the Intervention Model • Focus on “Critical Thinking” and a “Reflective Practice Framework” • Use of Motivational Interviewing Strategies • Incorporation of the NCFAS/NCFAS-R into the assessment, goal setting and service/treatment planning process • Greater focus on Functional Analysis of Behavior

27. Reflective Practice Model Personal Framework Planning Implementation Assessment Evaluation/Outcome

28. North Carolina Family Assessment Scale (NCFAS/NCFAS-R) • NCFAS: Assessment of family functioning on 5 domains of interest • Environment • Parental Capabilities • Family Interactions • Family Safety • Child Well-Being • NCFAS-R: includes all of NCFAS plus two additional domains unique to reunification • Ambivalence • Readiness for Reunification

29. NCFAS Rating Scale

30. Changes/Enhancements to the Program Development Process • Comprehensive Training for Therapists and Supervisors • Site Development Process: Program Start-up and Ongoing Consultation Process • Homebuilders Standards and Fidelity Measures

31. Homebuilders Training: 1970’s-1980’s Initial Homebuilders Training (3-4 Days) Special Topics (Anger Management, Depression, Assertiveness Skills) (3-4 Days)

32. Homebuilders Training: 2008 • Homebuilders Core Curriculum (4-5 Days) • Working with Drug Affected Clients: Motivational Interviewing and Relapse Prevention (3 days) • Assessment and Outcome-based Goal Setting (2 Days) • Implementing Cognitive and Behavioral Interventions (2 Days)

33. Homebuilders Training: 2008 • Improving Decision Making through Critical Thinking (2 Days) • Domestic Violence: Strategies for In-Home Practitioners (2 Days) • Working with Parents with Cognitive Limitations (1 Day) • Issues in Reunification (1 Day) • Ethical Issues for In-Home Practitioners (1 Day)

34. Homebuilders Training for Supervisors: 2008 • Core Curriculum for Homebuilders Supervisors (3-4 Days) • Program Consultation and Quality Assurance Skills for Homebuilders Supervisors (2-3 Days)

35. Program Development and Implementation Strategies • Program replication in Washington State and New York City:Homebuilders staff relocate to start new programs • Program development across the United States:Development of “site development” strategies and process

36. Site Development Strategies • Program start up TA and consultation • Initial and ongoing training • Weekly telephone consultation • Client record reviews • Quarterly on-site consultation visits including observations of home visits and team consultation

37. Fidelity Measures: Immediate Availability and Response to Referrals • Indicator: Provider agency does not maintain a waiting list. Performance Measure: When provider agency has an announced opening, eligible referrals are assigned to a therapist on the day of referral. • Indicator: Therapists meet with families within 24 hours of referral. Performance Measure: 75% of families receive their first face-to-face visit within 24 hours of referral; 85% of families receive their first face-to-face visit no later than the end of the day after the referral. If intake is NOT achieved within 24 hours, 95% of those records document the reason for not achieving this standard as being due to the family’s

38. Fidelity Measures: Promoting Safety • Indicator: Family safety is increased during the intervention • Performance Measures: When there is a threat of self-harm, child abuse or neglect, or physical violence between family members, 100% of interventions include a safety plan and, if applicable, a service goal to address the threat; in all cases when serious safety concerns exist, therapists maintain frequent contact with family members (at least daily; more if indicated); therapists strategically schedule sessions at times when there is increased potential for problem behavior to occur; therapists respond to crisis situations on a 24/7 basis.

39. Fidelity Measures: Promoting Safety • Indicator: Family safety is increased during the intervention • Performance Measures: When the NCFAS family safety domain is rated below baseline at intake, at least 80% of interventions show an increased rating in this domain at service closure; on the Homebuilders Referent Feedback Survey, therapists receive an average rating of 4.0 or higher on the question: “How satisfied were you that the therapist adequately addressed safety issues?”

40. Fidelity Measures: Comprehensive Assessment • Indicator: The therapist completes a comprehensive written assessment. • Performance Measures: Therapist completes a functional analysis of behavior; therapist completes the NCFAS/NCFAS-R; therapist gathers information in a variety of ways from various sources; family assessments include information about family strengths, values, skills, problems, needs and barriers to goal attainment.

41. Fidelity Measures: Cognitive and Behavioral Approach • Indicator: The therapist applies cognitive and behavioral principles and evidence-based strategies to facilitate behavior change. • Performance Measures: Therapist uses behaviorally specific, value neutral language to describe problems and strengths. Therapist helps family members understand how behaviors are affected by antecedents, consequences, past learning, life experiences, culture, and other factors. Therapist uses evidence-based behavioral strategies with families to increase and/or decrease behavior. Therapist helps families learn how to utilize behavioral strategies to increase, decrease or teach new behaviors to their children. Therapist use evidence-based cognitive strategies with families to effect change.

42. Program Evaluationand Outcome Measures • North Carolina Family Assessment Scale (NCFAS/NCFAS-R) • Behavior Change Measures • Placement Prevention/Reunification Rates • CPS/CAN Re-referrals • Consumer/Family Satisfaction • Referring Worker Satisfaction

43. Results of Meta Analysis of Homebuilders Model Review and analysis of all rigorous evaluations of Intensive Family Preservation Services (IFPS) programs. WSIPP sorted these evaluations based on fidelity to the Homebuilders model. Findings • IFPS programs that adhered closely to the Homebuilders model significantly reduced out-of-home placements and subsequent abuse and neglect. Estimated that such programs produce $2.54 of benefits for each dollar of cost. • Non-Homebuilders programs produced no significant effect on either outcome. Summary from “Intensive Family Preservation Programs: Program Fidelity Influences Effectiveness”, February, 2006. www.wsipp.wa.gov

44. Evaluations Demonstrating Fidelity to Homebuilders Model Blythe, B. & S. Jayaratne. (2002, March 22). Michigan Families First effectiveness study. <http://www.michigan.gov/printerFriendly/0,1687,7-124--21887--,00.html>, accessed 02/07/06. Feldman, L.H. (1991, December). Assessing the effectiveness of family preservation services in New Jersey within an ecological context. Trenton, NJ: Bureau of Research, Evaluation and Quality Assurance, Division of Youth and Family Services, Department of Human Services. Fraser, M.W., E. Walton, R.E. Lewis, P.J. Pecora, & W.K. Walton (1996). An experiment in family reunification: Correlates of outcomes at one-year follow-up. Children and Youth Services Review 18(4/5): 335-361. Note: This program is also evaluated by E. Walton (1998). Mitchell, C., P. Tovar, & J. Knitzer (1989). The Bronx Homebuilders Program: An evaluation of the first 45 families. New York: Bank Street College of Education. Walton, E. (1998). In-home family-focused reunification: A six-year follow-up of a successful experiment. Social Work Research 22(4): 205-214. Note: This program is also evaluated by M.W. Fraser et al. (1996).

45. Rigorous Experimental Study • Blythe & Jayaratne (2002) • High-risk families (court had approved child removal), true random assignment IFPS or traditional services (including foster care) • At 6 months • 94% of IFPS children at home/relative • 34% of non-IFPS children at home or with relative • At 12 months • 93% of IFPS children at home/relative • 43 % of non-IFPS children at home or with relative

46. Research: Random Assignment Studies Blythe, B. & Jayaratne, S. (2002). Michigan Families First Effectiveness Study. Retrieved April 24, 2006 from http://www.michigan.gov/dhs/0,1607,7-124-5458_7695_8366-21887--,00.html • 81% of treatment group avoided placement.• 51% to 61% of comparison group avoided placement. Fraser, M., Walton, E., Lewis, R., Pecora, P., & Walton, W. (1996). An experiment in family reunification services: Correlates of outcomes at one year follow up. Children and Youth Services Review, 18(4/5): 335-361. • 92% of the treatment group returned home.• 28% of the control group returned home. Feldman, L.H. (1991, December). Assessing the effectiveness of family preservation services in New Jersey within an ecological context. Trenton, NJ: Bureau of Research, Evaluation and Quality Assurance, Division of Youth and Family Services, Department of Human Services. • 57% of the treatment group avoided placement. • 43% of the control group avoided placement.

47. Research: Comparison Group Studies Fraser, M. W., Pecora, P.J., & Haapala, D.A. (Eds.). (1991). Families in Crisis: The Impact of Intensive Family Preservation Services. New York: Aldine de Gruyter. • 71% of WA treatment group; and 62% of UT treatment group avoided placement. • 15% of comparison group avoided placement. Mitchell, C., Tovar, P., & Knitzer, J. (1989). The Bronx Homebuilders program: An evaluation of the first 45 families. New York: Bank Street College of Education. • 74% of the treatment group avoided placement • 65% of the control group avoided placement. Wood, S., Barton, K., & Schroeder, C. (1988). In-home treatment of abusive families: Cost and placement at one year. Psychotherapy24(3), 409-414. • 74% of the treatment group avoided placement. • 45% of the control group avoided placement.

48. Research: Statistical Control Group Kirk, R.S. & Griffith, D.P. (2004). Intensive family preservation services: Demonstrating placement prevention using event history analysis. Social Work Research 28(1), 5-15. • 81% of treatment group avoided placement. • 51% to 61% of comparison group avoided placement.

49. What We Have Learned • Implementation of the Homebuilders Model isn’t easy and program development takes time and resources • Public and private agency support are critical to successful program implementation • Payment systems can support or hinder successful implementation • Ongoing training, consultation and quality enhancement are essential to long term success

50. What We Have Learned • Staff selection is critical – there must be a “job fit” • Supervisors are a key to successful implementation • A focus on maintenance of changes is critical – no program can be successful without other community supports and resources • Successful programs can easily be dismantled or diluted • Ongoing research is needed and difficult to accomplish