Total Clinical Outcomes Management

1. Total Clinical Outcomes Management CANS Conference Nashville September, 2008

2. Workshop Overview • Background to TCOM • Tensions and syndromes • The TCOM Framework • Keys to Successful Implementation

3. Background • 1980’s – quality initiatives • Focus on program services (not the individual child) • Movement toward articulating outcomes approach to care • The Measurement & Management of Clinical Outcomes in Mental Health (Lyons et al. 1997) • Total Clinical Outcomes Management (TCOM) • Embed quality assurance and quality initiative into clinical service • « …the measurement and management of information regarding the characteristics of children and families is the single most important focus of managing treatment interventions at all levels of the system of care simultaneously » Redressing the Emperor: Improving Our Children’s Public Mental Health System (Lyons, 2004), pg.100

4. Challenges to the Child-Serving System • Many different adults in the lives of our children/youth • Each has a different perspective and, therefore, different agendas, goals, and objectives • Honest people, honestly representing different perspectives will disagree • This creates the inevitability of disagreements and potentially conflict

5. Potential Solutions • If a primary challenge is ongoing disagreements then managing the child serving system is actually ongoing dispute resolution • The key principles of dispute resolution or conflict management are: • Identify the shared vision • Communicate about the shared vision

6. Tensions • “Competing pressures arising from the incompatible or opposing goals and objectives that push or pull the system in opposite directions” • « They are structural aspects of the system that cannot be eliminated, but must be understood and managed » Redressing the Emperor, Lyons 2004 (pg. 31 )

7. System Level Tensions • Multiple Models • Medical Model • Social Model • Central vs Local Control • Involvement of multiple state agencies/ministries and levels of government • Budget Silos vs Blended Funding • inpatient vs outpatient funding • Agency and Service Delivery Boundaries • Integration with community service providers (inpatient vs group homes) • Insurance Model vs Biopsychosocial Model

8. Program Level Tensions • Business Model vs Clinical Model • Occupancy rate vs best interest of child/youth • Accountability vs Quality Improvement • Leadership Salaries vs Line Staff Salaries • Liability vs Learning Culture Environment • Documentation driven by legalities vs clinical need • Clinician vs Administrator Tension • Time allocation: Administrative Duties vs Clinical Duties

9. Family and Child Level Tensions • The Unequal Information Tension • Parents vs Professionals – who cares more? • What youth want vs What Others Want for Them • Child Focus vs Family Focus • Parent Responsibility vs Parent Blame • Discipline expertise vs Team Consensus • I’ve assessed this child, I know this child best.

10. Syndromes “ Habitual maladaptive patterns of behavior that have developed as a result of the historical, philosophical and contextual environment in which children’s public mental health has developed.” Lyons, 2004 Syndromes develop in response to tensions.

11. System Level Syndromes • The political dog walk • Field of dreams • What’s mine is mine but what’s your’s, well, that’s negotiable Example: • “Not my job” – Level of supervision in group homes

12. Program Level Syndromes • Colonel Sander’s Syndrome • Therapist Illusion • Rose Reversal • Public Funding as an Entitlement Examples: • “Rules are Rules” – no visitors for 24 hrs, - lights out at 10:30 pm

13. Child and Family Level Syndromes • Expert Syndrome • Hammer-Nail Syndrome • Happy Face Syndrome • Ostrich Syndrome • Fuzzy Pathogen • Imagined Cure • Endless Treatment Example: • “What is the appropriate bedtime for a 9 year old?” – Parents vs team • Changing the CANS to reflect a personal view

14. II. TCOM – the Framework

15. Rethinking how we manage children’s services: Total Clinical Outcomes Management (TCOM) • The philosophy of TCOM is that the needs and strengths of the client/patient should drive the process of care. • The optimal means of achieving the goal of ‘uniform individuality’ is through the use of structured, evidence-based assessments. • Within the TCOM approach, standard assessment processes drive decision making at the individual child and family level, the program level, the hospital level, and ultimately, the system level. • The articulation of TCOM principles represents an important shift in how services are managed.

16. Rethinking how we manage children’s services: Total Clinical Outcomes Management (TCOM) • No longer are standardized clinical assessments the domain of research and evaluation only. • Rather these assessments become key components in the process of clinical service delivery. • Arbitrary lines between clinical operations and program evaluation are eliminated. They are the same thing. • Effective management, like good evaluation, requires accurate information, relevant to the objectives of the service.

17. Total Clinical Outcomes Management • Totalmeans that it is embedded in all activities with families as full partners. • Clinical means the focus is on child and family health, well-being, and functioning. • Outcomesmeans the measures are relevant to decisions about approach or proposed impact of interventions. • Managementmeans that this information is used in all aspects of managing the system from individual family planning to supervision to program and system operations.

18. Primary Tenet of TCOM • The primary tenet of TCOM is that effective services in complex child serving systems require a focus on a shared vision of the children and families receiving services. • Complex systems require the collaboration of multiple partners each with different mandates, agendas, and priorities. • The facilitation of communication among all system partners, including youth and families is necessary. • Despite differences, all partners share a commitment to serving children and families. • Accountability to the child and family is required between all partners at all levels

19. Collaboration and Communication Multiple Partners: Child / Youth Families Educators Caregivers (foster parents, group home staff, respite) Health Care Providers Case Managers Community Clinicians / Therapists Child Welfare Workers Probation Officers Administrators Agencies / Hospitals / RTC’s / Jails / Schools and School Boards Policy Makers Funding Sources (Government or Insurance) Courts

20. Judge Juvenile Justice Case Worker Child Welfare Case Worker Mental HealthCase Worker Educators Treatment Providers Youth’s Supporters Youth Others Youth’s Family Complex and confusing webs of accountability Hierarchical Structure Characteristics of Accountability Networks in Traditional Child Serving Systems Decision making authority concentrated at the top “Traditional” child serving systems are multisystemic and involve a variety of stake-holders, each with their own priorities, needs, and funding streams. These stakeholders typically include: Decisions flow downward Information flows upward

21. Juvenile Justice Case Worker Judge Mental HealthCase Worker Child Welfare Case Worker Treatment Providers Youth Others Educators Youth’s Family Youth’s Supporters Characteristics of Accountability Networks in Systems of Care An increase in the importance of collaboration, interdisciplinary team work and group decision making The” tighter” integration of stakeholders Systems of Care strive to replace traditional systems of hierarchical accountability with team-based and collaborative “circles of accountability” that are typically characterized by: A decrease in the importanceof authority determined solely by rank Flexible circular patterns of communication & accountability that are not constrained by formal structures An increase in “wraparound” sensibility

22. Paradigm Shift • Shift in management of services • Theoretical • Understanding the concepts and how they fit together • Personal Conceptualization • How the theory fits with one’s own personal values / professional identity and role • Practice • Integrating / translating theory into practice • Organizational • Documentation, process • Articulation • Language, terminology • Shift in vision • My vision Shared vision

23. Juvenile Justice Case Worker Judge Mental HealthCase Worker Child Welfare Case Worker Treatment Providers Others Educators Youth and Family Youth’s Supporters My Vision ? ? ? -Budget -Time -Theory -Scope of Practice -Values / beliefs ? ? ? ? ? Collaboration = Shared Vision

24. Juvenile Justice Case Worker Judge Mental HealthCase Worker Child Welfare Case Worker Treatment Providers Educators Youth and Family Youth and Family Youth’s Supporters Shared Vision ? ? ? Care Shared Vision ? ? ? ?

25. Understanding our Marketplace:The Hierarchy of Offerings I. Commodities: raw materials II. Products: mass produced from raw materials III. Services: hiring someone to apply a product IV. Experiences: memories V. Transformations: opportunities for change as a person or family - Gilmore & Pine, 1997

26. Further Challenge to the Child-Serving System • We have been managing services not transformations • You cannot manage what you do not measure • We must manage transformational offerings which requires that we measure the transformations.

27. Achieving Key Tenets • Maintaining the focus of assessments on children and families informs decision making at the five levels of the system • the individual child and family level • the program level • the hospital / agency level • the community level • the full systems level • A central management strategy is used to ensure that all decisions are informed by an understanding of the needs and strengths of children and families. • Assessments of needs and strengths of child and family (ie CANS) needs to be embedded within the clinical service

28. Child and Adolescent Needs and Strengths (CANS) Tool • CSPI was developed • CANS-MH builds on CSPI methodological approach but with broader conceptualization • Assessment • Communication to team / system of care • Decision support for service delivery • Quality assurance monitoring • Retrospective / Prospective • Reliability • Validity

29. Child and Adolescent Needs and Strengths: A Communimetric Measure • Psychometric Communimetric • Fewer items required, shorter measure • Immediate results, no need for scoring • Decision support focused • Levels of need translate directly into action levels • Measures are reliable at the item level • Tool must be meaningful to the service delivery process • All partners involved in communication process should be involved in design of measure • The value of the measure should be evaluated by its communication utility • Common language for multidisciplinary settings

30. Six Key Characteristics of a Communimetric Tool • Items are included because they might impact service planning • Level of items translate immediately into action levels • It is about the child not about the service • Consider culture and development • It is agnostic as to etiology—it is about the ‘what’ not about the ‘why’ (2 exceptions: trauma and social behaviour) • The 30 day window is to remind us to keep assessments relevant and ‘fresh’ • Numbers exist to add stories together=communimetrics

31. CANS –A Communimetric MeasureAction Level Key Needs: 0 - No Need 1 - Watch/Prevent 2 - Act 3 - Act Immediately/Intensively Strengths: 0 - Centerpiece 1 - Useful 2 - Potential 3 - None identified

32. CANS Tools • Sector: Mental health, juvenile justice, developmental, • Age: 0-5, YANSA, ANSA • Comprehensive: Illinois, Indiana, New Jersey, New York, Connecticut, Tennessee • Training Websites: • Indiana • http://www.communimetrics.com/CansCentralIndiana/ • New York • http://www.communimetrics.com/CansCentralNewYork/ • Illinois • http://www.dcfscansnu.com/

33. CANS Implementation • Tennessee: DCS  Implementation of the CANS in child welfare system • All child welfare case workers have been trained in the CANS.   • They have developed four University partners at Centers for Excellence (e.g. Vanderbilt, UT Memphis).  These partners have become trainers and supervisors and monitor the quality of all assessments.  • Agency: Choices Inc – Implemented TCOM approach in agencies in Indiana, Ohio, and Maryland. • They have embedded the CANS in their clinical management software system and use it for service planning, supervision, and program evaluation.  • Instrumental in supporting Indiana and Maryland in adopting the CANS.  • Indiana: FSSA  Design and implement a cross-systems CANS version • In the past years, partners from mental health, juvenile justice, child welfare, and schools participated in the design phase.   • Now implemented in juvenile justice, child welfare and possibly medicaid • A cross-systems web-management system was designed and implemented at that time, too.  More than 250 Super Users were created to facilitate the implementation process

34. Steps to Transformation

35. TCOM Grid of Activities

36. Service Planning

37. Interdisciplinary Action Plan

38. Matching Needs to Evidence-Based Practices • Trauma • SPARCS • TF-CBT • Parent-Child Psychotherapy • Oppositional Behavior • Collaborative Problem Solving • Depression • CBT

39. Eligibility

40. Decision models using the CANS • Profiles of actionable needs including patterns of ‘2’ and ‘3’ ratings rather than total scores with cut-offs • Supports decisions rather than makes them • Evidence that CANS recommended level of care associated with improved outcomes

42. Resource Management

46. Service Transitions & Celebrations

47. Service Transitions & Celebrations • Discharge from one program should be the starting assessment of the next. • Families tire of repeated and ceaseless assessments. • Sharing outcomes using structured assessments communicates differently than a ‘buddy-hug’ and ‘good job’.

48. Program Evaluation

49. Children’s Unit Program Review • What do we know about our children and families? • Reviewed clinical and demographic information on the children and families we served • Literature Review • Trauma • Phone Survey • Formed a workgroup of staff who do programming • Retreat Day

50. Key Demographics – Gender & Age