Articulating A Practice Model Of Service Integration Alberta College of Social Workers Annual Conference 2008

1. Articulating A Practice Model Of Service IntegrationAlberta College of Social Workers Annual Conference2008 Scott Smillie, BSW; RSW Christa Gilroy, BSc., Human Ecology Valerie Streit, BA.,RLS Susan Watson, BSc., Home Economics

2. Introductions: Round Robin Workshop participants to introduce themselves, interest in the workshop topic, and their learning interests/objectives for this workshop. Presenters Workshop Objectives: • Share our experiences and learning. • Receive input into “The Model”.

3. Objectives You Will: • Learn about a community based research project, focused on discovering the benefits of service integration for low-income families. • Explore the development process and how program development and community engagement fit within the process. • Hear about the complexities and key processes of community based research within the context of a paraprofessional, multi-sectoral, Randomized Control Trial

4. Objectives: cont. • Learn about the Families Matter Partnership Initiative (FMPI) program, practices conceived, (practice theories & principles adopted) and the need/importance of developing and providing a conceptual program model for management purposes. • Explore the concepts imbedded within the “Ecological Model of Service Integration” and provide input regarding its validity.

5. Historical Context Dec. 2000 – Release of “Listen to the Children” by Quality of Life Commission. June 2001 – Decision made to focus on improving existing services. March 2002 – Workshop on “When The Bough Breaks” & “Benefitting all the Beneficiaries”. August 2003 – Logic Model Initiated July 2005 – RFP went out. Aug. 2005 – YMCA granted service delivery contract. January 2006 – FMPI started receiving referrals from research recruitment and data collector team.

6. Alberta Context:Support to Low-Income Families • In Edmonton, about 27,000* families (15% of all Edmonton families) are considered low income, and struggle to make ends meet. • These families have limited resources, often barely enough to pay for food and shelter. • As well, they often have little opportunity to learn skills, access preventive health care, or enjoy family activities. *Urban Poverty Project, CCSD, 2001

7. Support to Low-Income Families • Although there are agencies and supports available to help, these families also have difficulty accessing supports. • Transportation, awareness, language, and culture are among the barriers to accessing supports. • Families with low-incomes are also more likely to have other social and health needs.

8. Support to Low-Income Families • Interpersonal/family relationships, life skills, parenting…or just the ability to play. Difficulty with these issues can put stress on the whole family. • Supporting families can help build on their strengths, set goals, and make dreams come true. • But, how do we know what works best?

9. Who is Families First Edmonton? Families First Edmonton is a partnership with two co-leads, Alberta Employment, Immigration & Industry, and the City of Edmonton Community Services. They are joined by 10 other organizations, a service provider, and researchers from the Community-University Partnership at the University of Alberta.

10. Partners In Families First Edmonton Project Co-Chairs: • Alberta Employment, Immigration & Industry • City of Edmonton Community Services Service Delivery Providers: • YMCA of Edmonton • Multi-cultural Health Brokers Cooperative • Bent Arrow Traditional Healing Society • KARA Family Resource Centre Members: • Alberta Children’s Services • Alberta Health and Wellness • Alberta Mental Health Board • Capital Health • Edmonton Aboriginal Urban Affairs Committee • Edmonton Community Foundation • Edmonton & Area Child and Family Services Authority – Region 6 • Quality of Life Commission • United Way of the Alberta Capital Region • University of Alberta – Community – University Partnership for the Study of Children, Youth, and Families (4 Universities Involved).

11. What is Families First Edmonton? • Families First Edmonton is a $10 million research project to determine whether delivering health, family support and recreation services in a coordinated way can lead to better outcomes for families with low incomes. Families First Edmonton seeks to determine the most cost-effective, efficient use of resources to proactively assist families. • The research project is based on a similar study conducted in Ontario by Dr. Gina Browne. Her award winning study concluded that when families with low incomes are provided health, social, childcare and recreation in a comprehensive and combined way, families benefit more and governments realize cost savings. There was a desire to build on the Gina Brown study, but within an Alberta context. • Families First Edmonton will determine if similar positive results can be seen in Alberta with an adapted and enhanced approach, that takes into account the differences between Alberta’s and Ontario’s economy, social service environment, legislation, programs and processes.

12. What is Families First Edmonton? Cont. • FFE was seeded out of a broad realization that low-income families receiving income support are not connecting with other community services. • A research hypothesis arose that perhaps if we become more deliberate in reducing barriers to services for families by improving the integration of existing services, that families and their children would experience improved health and development outcomes. • A research framework and service delivery framework were developed to test key research questions.

13. Research Framework: Involved key research questions: • Does FFE service delivery model enhance families’ access to established services? • What are the effects of the service delivery model on the quality of life of family, type of service accessed, and the level of satisfaction families feel toward the existing services? • What are the costs to service systems of each of the service delivery models over time? • What are the achievement outcomes of the children, and physical and psychosocial health outcomes of family members, over time, associated with each of these delivery models? • What are the role of problem solving skills, communication skills, and family connections to community on the intervention effects of four service delivery models, and how does this role change over time? • Do socio-demographic characteristics influence the family linkages to services and the outcomes in cost and health?

14. Research Approaches: • FFE is a Randomized Control Trial (evidence based) • FFE sought a sample size of 1200 families • A Recreation Pilot was implemented and utilized to base some research decisions upon. • Recruitment Targets and Strategies.

15. Participant Eligibility • Eligible families contacted by mail at random • Completely voluntary To be eligible, families must: • have at least one child aged 0-12 years • be receiving Alberta Works Income Support and/or Alberta Child Health Benefit for the past six months • live in designated area: north-central and north-east Edmonton (This changed to city wide).

16. What Does Success Look Like? Researchers will determine which approach most successfully achieves the following outcomes among participants in the project: • Increases appropriate access to existing social, health, and community services • Enhances physical and psycho-social health of the families • Increases attendance and achievement at school • Decreases the number of behavioural/emotional problems among children in the study • Increases self-reliance and enhances life management (e.g. grocery shopping, appropriate child care, etc.)

17. What Does Success Look Like? - Continued • Decreases use of emergency services (emergency medical services, hospital emergency, child welfare, police, etc.) and increases proactive use of health promotion services • Is most cost-effective by avoiding future costs or being cost-neutral, while achieving better results • Results in more efficient use of existing resources • Increases the ability of agencies and organizations to work together across sectors

18. Test 4 Service “Models” • The Family Healthy Lifestyle Program: The family will continue to receive the same services they do now plus a family support coordinator helps the family solve problems and link to health, education, child care, and family support services in the community. • The Recreation Coordination Program: The family will continue to receive the same services they do now plus a recreation coordinator helps place the children (0-17 years) into recreational programs with some funding provided. • The Comprehensive Program: The family receives the same services they do now plus a combination of the Recreation and Family Healthy Lifestyle Program

19. Test 4 Service “Models” - Continued • Self-Directed Group The self-directed group will continue to access high quality services in the usual manner. Data will continue to be collected at intervals consistent with the other three groups. The self-directed group will allow researchers to compare the delivery of the three service models to how services are delivered without them.

20. Service Provider The YMCA is contracted to provide services to participating families. The YMCA joined with the Multicultural Health Brokers Cooperative, KARA Family Resource Centre, and Bent Arrow Traditional Healing Society; to coordinate a comprehensive array of services to families involved with FFE. Together, they form “Families Matter Partnership Initiative.”

21. Service Delivery Framework: • Named FMPI (Families Matter Partnership Initiative) • Separated from influences of research side. • Each program stream to be distinct. • All programs shared common practices. • 4 Practice Pillars in Common: family centred; culturally sensitive; capacity building, reflective practice.

22. FFE models: assisted services Models will enhance service integration and family capacity building Recreation Family Healthy Lifestyle • 300 families • Rec. Assessment • Active outreach • (placements, follow-up • & funding) • Other needs self-directed • Recreation Coordinators • 300 families • Holistic Assessment • Supportive brokerage • (service-links & follow-up) • Recreation access not • funded • Family Support Coordinators Comprehensive • 300 families • Holistic Assessment • Services based on needs • Rec Assessment • Placements, follow-up & • funding • Family Support Coordinators

23. Overview of Service Delivery Framework & Deliverables A collection of theories and principles from various sources:

24. Service Delivery Deliverables – Common To Each Service Stream • Quick engagement of families • Family Assessment • Goal Setting/planning • Progress Reports/monitoring • Intervention Fidelity

25. Tier 2 (Emerging, Maintenance & Self-Sufficient) Tier 1 (Intense Engagement) Tier 3 (Transition & Closure) “I HAVE” “I AM” “I CAN” AWARENESS Knowledge Skills Attitude Awareness KNOWLEDGE Skills Attitude Awareness Knowledge SKILLS Attitude Awareness Knowledge Skills ATTITUDE Initial Initial ContactAssessment  IPP  Wrap Up - 3 months to end Family interacting interdependently or End of Research (reasons for leaving program may vary)  Implementation - ie. Feedback from referring source Ie. Involvement in programs Unique Action Plan) Secondary Referral Assessment Based on tthe PLM Learning Process To Service Integration Active Outreach Approach Mapping a Change Process and Goal Attainment with NO timelines attached Facilitating a Learning Process (AwarenessKnowledgePracticalAttitude) • ** Notes: • Prior to Initial Contact Data has been collected and referral has been made to Coordinators • Progress within Tiers is determined by level of need of the Families • Progress may vary– ie. May stay in Tier 1 continuously, may jump from Tier 1 to 3 or Tier 2 back to 1 etc. • Exit/Entry may vary– may enter at Tier 3 or leave at Tier 2, etc. • Awareness, Knowledge, Skills and Attitude may be developed/pre-existing at any level

26. Do these array of Practices, Theories and Deliverables Constitute a Service Delivery Model? • How does this framework help us to ensure intervention fidelity? • The information void!

27. Personal Change Process Skills Knowledge Ecological Model to Service Integration Service Integration Spectrum Helping Change Relationship Weighting Awareness Marginalization Dependence I HAVE Interdependence I AM Independence I CAN W = 50% C = 50% W = 10% C = 90% W = 90% C = 10% Basic Social Self Actualization Hierarchy Of Needs Personal and Societal Well Being Personal and Societal Well Being Personal and Societal Well Being

28. Personal and Societal Well Being Personal Change Process Tier 3 Tier 2 Service Integration Spectrum Helping Change Relationship Weighting Tier 1 Personal and Societal Well Being Personal and Societal Well Being Tier 3 Tier 2 Tier 1 Tier 1 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3 Hierarchy Of Needs Personal and Societal Well Being

29. The Ecological Perspective • “The ecological perspective uses ecological concepts from biology as a metaphor with which to describe the reciprocity between persons and their environments… attention is on the goodness of fit between an individual or group and the places in which they live out their lives” (Sands, 2001).

30. The Ecological Perspective: Brief History • In the mid 20th. Century, the Family Systems model was adopted, that incorporated a perspective that family members are influenced equally by environmental systems with equal power. This perspective has been expanded to “explain that an individual is ‘constantly creating, restructuring, and adapting to the environment as the environment is affecting them’ (Ungar, 2002). The systems approach now added the social elements to the interactive process. In the 1960’s and 1970’s, the systems theory was expanded based on an ecological approach, breaking down the term ‘environment’ into social determinants with varied levels of power and influence, as deemed by individual stress and need and level of connectedness. Unlike most behavioural and psychological theories, ecological theories focus on interrelational transactions between systems, and stress that all existing elements within an ecosystem play an equal role in maintaining balance of the whole.”

31. Systems in Environment: • Bronfenbrenner (1979), suggests four levels of ecological components as a useful framework in understanding how individuals or family processes are influenced by hierarchical environmental systems in which they function: the Microsystem, Mesosystem, Exosystem and Macrosystem.

32. The Relationship of the Ecological Model of Service Integration to the FFE Logic Model: • Families first is a large and complex project. The logic model itself, which is usually a visual schematic of a single page, is 17 pages for this project. The 4 overarching goals of the project encompass micro issues related to service interventions with families and macro issues such as informing policy changes and research. For any individual in the project, understanding ones role and relationship in relative to these larger goals can be mind boggling. The Ecological Model helps the front-line worker to conceptualize and link how their work at the microsystems level is linked to, and supports the broader goals of the project. • To be an effective link therefore, the principles encompassed in the model need to be congruent with the Logic Model. Such congruence can be found in many parts of the logic model document. For example: • The first page of the logic model has a section called “Statement Of Need”. This is consistent with the ecological model premise that needs are an important area of focus for assessing conditions of well-being that the interventions seek to improve upon.

33. Relationship Continued: • In the Rationale: Notions of diversity, interconnectedness between families, staff and community; inclusive, mutually respectful and equitable communities, are all concepts that fit within an ecological model. p.2 • The notion of a relationship between “Outputs” and “Activities” that result in “Outcomes” speaks to the need for the strong capacity of community systems to support the interventions. This again demonstrates the relationship between private troubles and public issues and the fit for individuals in their environment. Families can not thrive in a community that doesn’t has the capacity to support them. • “The basic premise of a community-based approach is the recognition that services should be accessible, continuous, comprehensive, and coordinated…..”p.2 A service delivery model outlines in a conceptual framework principles that respond to the need to ensure these community based approaches are honored. The coordinated piece of this, supports intervention fidelity. • “Adequacy of social support is a very important foundation of family adaptation and hence child development”p.3. This notion of adequacy is linked to the degree of fit between individuals and their environment, which is an ecological concept. • In The Four Overarching Goals: The logic model outlines four overarching goals that illustrate a hierarchical conceptualization of systems related to improving upon service integration. The ecological model places the FMPI intervention at the micro, meso and exosystem levels without mitigating its interrelationship to the 4th. Goal which is clearly at the macro systems level. • Goals of increased family capacity, sustained collaborations amongst systems stakeholders, improving community responsiveness to family needs, documenting practices, and informing research, policy and systems, all speak to an ecological approach to working with the range of issues families face.

34. Goal 1 and Practices: • The logic model outlines 1-2, 2-3, and 3-5 year outcomes for families, related to the goal of families gaining increased capacity to access services. This suggests a linear progression of change experienced by families. • The logic model describes these outcomes in a manner that reflects increased awareness, knowledge, skills and changed attitudes of families. The ecological model provides a visual schematic of this linear progression. This outcomes are targeted through a experiential learning approach with families and is reflected in the ‘Personal Change Process’ quadrant of the model schematic. • The logic model also acknowledges the importance of families moving from a state of dependence, to independence to interdependence with their environment. Short Term: “family accepts responsibility for some aspect of the linkage process”; Intermediate: “Family follows up on linkages on their own. ….Family is more connected in their community.” Long-term: “Family demonstrates sustained ability to apply learned problem solving skills. ….demonstrates increase self-confidence and efficacy.”p.8 These goal statements are reflected in the ecological model in the ‘Service Integration Spectrum’ quadrant as well as the ‘Helping Change Relationship Weighting’ quadrant of the model schematic.

35. What Benefit Does This Ecological Model Serve To The FFE Project There are benefits to FFE at 3 levels: At the front-line worker level: Front-line worker are motivated to do this work with families, in part because of the value of contributing towards research and potential outcomes that go beyond working with the family. These same workers however, may struggle with how their role contributes to the larger picture. Without this understanding, workers can lose perspective of the program parameters and lose their motivation to work within these parameters. At the service delivery level, a model serves the following purposes: • Provides a contextual framework with which to train workers and support their work with families. • Clarifies outcomes that the workers practices aim to achieve. • Provides a reference point to start family work and a process and check points along the way to assess and reflect on this work. • The model can articulate the broader areas of practice domains from where service delivery strategies are framed.

36. Front-line Workers Continued: • The model helps to differentiate an ecological approach from other philosophies that are perhaps more focused on families as independent units in isolation from their communities. • Models are value and philosophically based and the ecological model encompasses many of the practice principles stakeholders felt were important. A conceptual model helps workers to understand these sets of values and practice principles. (see appendix for description of theories and principles). • The model hypothesizes that family needs can change and evolve within a supportive learning environment, where the degree of engagement and the roles in the reciprocal relationship between worker and client changes as families move through a spectrum of empowerment and healthier inter-dependence with their communities. Using an assessment strategy, this model attempts to measure this change process. • The model provides the opportunity to measure and inform the change process, providing the necessary tools for case management and caseload management. Imbedded within these processes is the notion of Intervention Fidelity, that is, ensuring a consistent quality and measurable degree of service for families.

37. Benefits continued: At the Community Stakeholder Level:(including funders, service delivery partners, etc.) • It provides awareness of the values, practice principles and theories with which the service providers are operating from and delivery interventions. • It builds confidence that ‘good practices’ are being incorporated and the service delivery providers have the necessary knowledge and skill base to provide services. • The model provides an opportunity for examination and engagement into the area of developing innovative practices.

38. Benefits continued: • At the Research Level: the conceptual model provides the following: • Provides the research partners with the broader practice framework that service delivery is working from. • A broader service delivery framework, described in a conceptual model acts as a reference point to evaluate the service delivery teams understanding of intervention goals in relationship to the Logic Model, conceived by a broader set of stakeholders. • This degree of understanding is important to determine how service delivery activities will support the outcomes listed in the Logic Model. • The ecological model also helps to clarify disparities in other documents. For example, the dose of intervention (stipulated in the RFP) appears to be linked to the notion of linking families to services while the logic model supports practices associated with a learning process with families that develops their capacities to be less dependent upon services. This latter service objective is not reflected in the smaller service doses prescribed and associated simply with linking families to services. The ecological model to service integration bridges both of these objectives, dispelling any confusion that service dosage parameters may imply that capacity building and service integration are some how unrelated concepts.

39. What is Intervention Fidelity? “the adherence and competent delivery of an intervention by the interventionist as set forth in the research plan” Source: Santacroce, Maccarelli & Grey, 2004, p. 63

40. Components of Intervention Fidelity • Adherence (or integrity) The degree to which a given intervention is implemented in accordance with essential theoretical and procedural aspects of the model • Competence The level of interventionist skill in utilizing core intervention techniques and responding to the unique needs of each participant • Differentiation The theoretical distinctiveness of the model’s main intervention principles in comparison to those of other models of interest or within efficacy trials, in comparison to those of competing study conditions

41. Researcher questions directed at establishing intervention fidelity for the FFE service integration practices: Adherence: • What are the practices associated with the awareness, knowledge, skills and attitudes of FFE service integration? • Are practices implemented consistently? • How do the key elements of FFE appear in the service integration practices: being family centred, culturally responsive, building capacity, and reflective practice?

42. Researcher questions directed at establishing intervention fidelity for the FFE service integration practices: Competence: • How do the interventionists implement the practices associated with the awareness, knowledge, skills and attitudes of FFE service integration? • How do the interventionists focus on the key elements of FFE service integration in their work? • How do the interventionists use their uniqueness in their implementation of the FFE service integration practices? • How does Families Matter support the interventionists in their service integration practices?

43. Researcher questions directed at establishing intervention fidelity for the FFE service integration practices: Differentiation: • Are each of the FFE service integration vehicles (Family Healthy Lifestyle and Recreation Coordination Programs) distinct? • How does Families Matter keep the FFE service integration vehicles distinct?

44. What Is Intervention Fidelity in Summary • Intervention fidelity is about doing what you said you would do. • Intervention fidelity is about protecting your interventions from influences that can “water down” or “change” the impact of the intervention. • A lack of intervention fidelity therefore, makes it hard to determine if the intended interventions can be attributed to causing the measured outcomes. • The strength of a randomized control trial is “controlling” the amount and type of intervention, so that outcomes aren’t attributed to other variables (in-deliberate or unplanned for activities/influences), which creates “Rival Hypothesis”. • What we want to accomplish is to create as much certainty as possible about which practices/interventions resulted in which outcomes. Without this certainty, it is difficult to replicate the interventions. The short coming of some similar studies has been that even though positive outcomes were noted, the research couldn’t clearly demonstrate the practices that led to those outcomes, making it difficult to replicate. It also makes it difficult to confidently be able to generalize the findings to those outside of the study, who we wish to serve, weakening the impact from a public policy perspective.

45. Why Is Intervention Fidelity Important? • Increases the likelihood of an effect for FFE through: • Internal Validity and the ability to attribute the effect of FFE to the FFE Interventions. • External Validity and the ability to generalize effects beyond the project participants • Increases the validity of findings that helps to answer the original Research Questions • Supporting Methodology • Increases retention • Increases Confidence of Stakeholders • Replicability/Transferability of FFE

46. Why Is Intervention Fidelity Important? • Improves FFE intervention through the discipline of consistent monitoring and feedback • Is the foundation of evidence-based practice • Promotes the avoidance of harm to partners/participants by: • Improving outcomes • Increasing the ethical component • Reducing unintended consequences • Enhancing reputations/confidence

47. Replicability Is A Goal Of FFE • Project 5, FFE Models, Approaches, and Practices, is a program evaluation that includes intensive analyses of the implementation of the different service-delivery models. These analyses are critical for determining the fidelity and effectiveness of the service-delivery models, and also for documenting practices (including engagement and retention) so that the lessons learned can be maintained and transferred (Appendix 1E).Drummond, J.E., Family First Edmonton, Year 1 Research Proposal, p.12b

48. Importance of Intervention Fidelity • In short, Intervention Fidelity can best be achieved by ensuring all stakeholders are on the same page. The logic model as a tool, is the visual schematic that describes the nuts and bolts of the intervention. As a process, logic modeling reinforces continuity and collaboration that supports clarity, reinforces adherence in the implementation of program interventions, and the differentiation of different interventions being tested. (The FFE Logic Model is a 17 page document that does not offer a clear visual schematic).

49. Variables Needing To Be Managed To Ensure Intervention Fidelity • Human Resource Management • Distinct Programs with Common Practices • Equitable caseload management, ensuring ‘dose’ of intervention, mitigating worker burden/bias, inconsistent practices, etc. • Consistent practices – data monitoring. • Clarity of outputs and outcomes.

50. Intervention FidelityAdherence & Competence:Best Practices