John S. Lyons, Ph.D. University of Ottawa Children’s Hospital of Eastern Ontario

1. Building a System one Child/Family at a Time: Total Clinical Outcomes Management and Treatment Planning John S. Lyons, Ph.D. University of Ottawa Children’s Hospital of Eastern Ontario

2. Three essential problems • Fundamental misunderstanding of the nature of our business • Our business is complex • System expertise is not resident among those with the most contact with the people we serve

3. Understanding our Marketplace:The Hierarchy of Offerings I. Commodities II. Products III. Services IV. Experiences V. Transformations - Gilmore & Pine, 1997

4. Challenges in the Human Service System • Many different adults in the lives of the people we serve • Each has a different perspective and, therefore, different agendas, goals, and objectives • Honest people, honestly representing different perspectives will disagree • This creates the potential for conflict

5. So what’s our problem? You can’t manage what you don’t measure • You need good information to make good decisions • You can try to fake it. • You can rely on intuition. But even good intuition is limited as a management strategy • Collecting information is measurement

6. Example problems with managing transformations as services • Focus on finding people and getting them to show up rather than finding people you can help, helping them and then finding some one else • Assessment used to justify service receipt rather than to understand and communicate • An hour is an hour is an hour—time valued equivalently over an episode • Supervision as enforcement rather than teaching

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

8. Managing Tension is the Key to Creating an Effective System of Care • Philosophy—always return to the shared vision. In the mental health system the shared vision are the people we serve • Strategy—represent the shared vision and communicate it throughout the system with a standard language/assessment • Tactics—activities that promote the philosophy at all the levels of the system simultaneously

10. The Strategy: CANS and ANSASix Key Characteristics of a Communimetric Tool • Items are included because they might impact care planning • Level of items translate immediately into action levels • It is about the individual not about the individual in care • Consider culture and development • It is agnostic as to etiology—it is about the ‘what’ not about the ‘why’ • The 30 day window is to remind us to keep assessments relevant and ‘fresh’

11. CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS-MH) Use with manual dated 1/5/08 PROBLEM PRESENTATION 0 1 2 3 NA 1. Psychosis  2. Attention Deficit/Impulse  3. Depression/Anxiety  4. Oppositional Behavior  5. Antisocial Behavior  6. Substance Abuse  7. Adjustment to Trauma  8. Attachment  RISK BEHAVIORS 0 1 2 3 U 9.Danger to Self  10. Danger to Others  11. Other Self Harm  12. Elopement  • Sexually Abusive Behavior  • Social Behavior  • Crime/Delinquency  FUNCTIONING 0 1 2 3 U 16. Intellectual/Developmental  17. Physical/Medical  18. Sleep  19. Family  20. School Achievement   21. School Behavior   22. School Attendance   23. Sexual Development 

12. Other Self Harm This rating includes issues of recklessness, engaging in unsafe behaviors that are putting the child or youth in jeopardy of physical harm.. A rating of 2 or 3 would indicate the need for a safety plan. 0 No evidence of behaviors other than suicide or self-mutilation that place the youth at risk of physical harm. • History of behavior other than suicide or self-mutilation that places youth at risk of physical harm. This includes reckless and risk-taking behavior that may endanger the youth. 2 Engaged in behavior other than suicide or self-mutilation that places him/her in danger of physical harm. This includes reckless behavior or intentional risk-taking behavior. 3 Engaged in behavior other than suicide or self-mutilation that places him/her at immediate risk of death. This includes reckless behavior or intentional risk-taking behavior.

13. CAREGIVER NEEDS & STRENGTHS 0 1 2 3 U NA • Physical/Behavioral Health  • Supervision  30. Involvement  31. Knowledge  32. Organization  33. Resources  • Residential Stability  35. Safety  STRENGTHS 0 1 2 3 U NA 36. Family  37. Interpersonal  38. Relationship Permanence  39. Educational  40. Vocational  41. Well-being  42. Optimism  43. Spiritual/Religious  44. Talents/Interests  45. Inclusion  46. Resiliency  47. Resourcefulness 

14. Talent/Interests This rating should be based broadly on any talent, creative or artistic skill a child or adolescent may have including art, theatre, music, athletics, etc. 0 This level indicates a child with significant creative/artistic strengths. A child/youth who receives a significant amount of personal benefit from activities surrounding a talent would be rated here. • This level indicates a child with a notable talent. For example, a youth who is involved in athletics or plays a musical instrument, etc. would be rated here. 2 This level indicates a child who has expressed interest in developing a specific talent or talents even if they have not developed that talent to date. 3 This level indicates a child with no known talents, interests, or hobbies.

15. Traditional Psychometric Measures } Behaviors Experiences Assets Relationships Care Planning The Child and Family Communication Measurement

16. States with CANS Presence: --Alaska --Kentucky --Montana --S. Carolina --Arizona --Louisiana --N. Carolina --Washington --California --Maine --N. Dakota --Delaware --Michigan --Ohio --Georgia --Minnesota --Pennsylvania --Kansas --Missouri --Rhode Island CANS Usage in the United States State-Wide CANS Usage: --Alabama --Iowa --New Jersey --Utah --Colorado --Maryland --New York --Virginia --Connecticut --Massachusetts --Nevada --W. Virginia --Florida --Mississippi --Oregon --Wisconsin --Indiana --Nebraska --Tennessee --Illinois --New Hampshire --Texas

17. TCOM Grid of Tactics

19. Services and Policy Research Perspective • Large databases are impressive but without clinical logic can be very misleading • Mental health is different than health care in terms of the information used to make decisions • Communimetric tools can be expected to have 100% use penetration

20. Figure 5.2 Survival analysis of time to placement disruption for children/youth whose placement matches CANS recommendations (Match=0), those whose placed is at a lower intensity than recommended (match=1) and those whose placement is more intensive than recommended (match=-1).

25. Prevalence of actionable needs on the Fire Setting item of the CANS by demographic characteristics. • N % Confidence IntervalGender Actionable of percentage • Female 2,063 0.87 (0.52 - 1.38)Male 2,092 1.82 (1.29 - 2.48) • Race/Ethnicity African American 2,002 1.38 (0.91 - 2.00) Non-Hispanic White 1,900 1.21 (0.77 - 1.81) Hispanic 233 2.15 (0.70 - 4.94) • Age 0 to 3 years 1,698 0.0 (0.0 - 0.22) 4 to 6 years 565 1.06 (0.39 - 2.30) 7 to 9 years 451 1.55 (0.63 - 3.17) 10 to 13 years 554 3.43 (2.08 - 5.30) 14 to 16 years 572 3.67 (2.29 - 5.56) 17+ years 89 3.37 (0.70 - 9.54)

26. The relationship of trauma experiences to the likelihood of having an actionable fire setting behavior. Number of Percent Traumatic n Actionable None 1,061 0.49 (0.16 - 1.14) One 1,129 0.89 (0.43 - 1.62) Two 885 0.79 (0.32 - 1.62) Three 559 2.50 (1.38 - 4.17 Four 296 1.35 (0.37 - 2.31) Five 151 3.97 (1.47 - 8.45) Six or more 119 8.40 (4.10 - 14.91)

28. Client –Level Formulation / Progress

29. Mental Health-Juvenile Justice Program CANS: Mental Health Needs percent of youth with actionable needs (2 or 3 ratings)

30. Dashboards

31. Figure 1. Level of Need by Year for Admissions into Residential TreatmentN=2782

32. Figure 6. Comparison of total score for RTC, CMO, and YCM initial assessments by year

33. Figure 8. Average Improvement over the course of Residential Treatment by Year Note: higher score better improvement)

34. Outcome Trajectories by program type in New Jersey

35. Hinge analysis of outcome trajectories prior to and after program initiation

36. Illinois Trajectories of Recovery before and after entering different types of Child Welfare Placements

37. Percent of hospital admissions that were low risk by racial group Adapted from Rawal, et al, 2003

38. Key Decision Support CSPI Indicators Sorted by Order of Importance in Predicting Psychiatric Hospital Admission Ratings of ‘2’ and ‘3’ are ‘actionable’ ratings, as compared to ratings of ‘0’ (no evidence) and ‘1’ (watchful waiting).

39. Change in Total CSPI Score by Intervention and Hospitalization Risk Level (FY06)

40. “It is the reformer who is anxious for the reform, and not society, from which he should expect nothing better than opposition, abhorrence and mortal persecution.” Mahatma Ghandi

41. Cast of Characters: Late Adopters • Columbo “If I act dumb maybe I can lower expectations and no one will expect me to change” • The Smartest Person in the Room “I already do this and have for some time now so why should I change. What you are saying is no different from what I’ve already been doing” • The English Major “What exactly do you mean by this word…. I need clarity before I can change. You do realize that there are typos in this manual” • Nervous Nelly “We just aren’t quite ready to start doing this today….tomorrow doesn’t look good either” • The Philosopher “Do we really understand what this means…” or “isn’t it really much more complex than this….We need to think this through” • The Uber-Professional “This is not in my mandate, it would be unethical…..” • The Uber-Bureaucratic. “Let’s do it. We’ll start with a subcommittee to explore the feasibility of considering it through the larger committee…” • The Ostrich “If I don’t see it, it doesn’t exist….” • The Slacker “If I just don’t do it maybe no one will notice”

42. Keys to Successful Implementation • Take it a step at a time—planned incrementalism. Implementation fatigue can drag change to a stop. • Don’t get the approach confused with the technology that supports it. • Focus where the work starts—individual care planning with children/youth and families. • Transparent use creates reliability and validity • Do not assume that training is an event. It is a process. • Reach out to others who use the approach. It is designed as a mass collaboration.

43. 1. Problem Identification 2. Problem Analysis 5. Plan Evaluation 3. Plan Development 4. Plan Implementation Integrating Total Clinical Outcome Management into Program Planning