Eric J. Bruns and Elizabeth Feldman University of Washington

1. Enhancing Implementation of Evidence Based TreatmentsWraparound, Care Coordination,Family Engagement, and Family Support Eric J. Bruns and Elizabeth Feldman University of Washington Division of Public Behavioral Health and Justice Policy ebruns@u.washington.edu / esfk@u.washington.edu Jeanette Barnes Mental Health Division and Mental Health Transformation Project BarneJK@dshs.wa.gov Evidence Based Practice Institute Forum Lacey, Washington March 13, 2009

2. Goals for this session • Identify common barriers to positive outcomes for children, youth, and families who seek help • Review several treatment enhancement strategies that are becoming more common in Washington and nationally • Family engagement strategies • Wraparound care coordination • Family advocacy and peer-to-peer support • Implications for clinicians in Washington State

3. The Big Picture • What are the needs of youth and families you work with? • What needs get met? • What needs do not get met?

4. What families need vs. get Need 86% 85% 84% 85% 83% 65% 65% Get 77% 81% 74% Difficult? 48% 41% 43% 74% 66% 69% 64% Special Ed svcs Psychologist Counselor Respite Parent Support Sibling Support Advocacy svcs 17% 53% 15% 31% Friesen & Huff, 1996

5. Anxious or Avoidant Behaviors Attention and Hyperactive Disorders Autistic Spectrum Disorders Disruptive and Oppositional Behaviors Self-harming Behaviors Assaultive and Aggressive Behaviors Sexually Aggressive Behaviors Traumatic Stress Interpersonal problems Substance use Delinquent behavior History of abuse and neglect We have treatments with evidence for effectiveness for…

6. Evidence based treatments • Well-defined • Usually Manualized • Results of rigorous research studies show that they are more effective than some other option • However… they often do not work in “real world” settings

7. In the Real World,Treatments Have Little to no Effect Children & Adolescents MH Treatment Studies: University Research Adult MH treatment studies: University Research Mean Effect Sizes found in Meta-Analyses of Therapies Clinic settings Weisz et al., 1995

8. Why do Treatments Have Little to No Effect in the “Real World”? • Lack of resources for community providers • Child and family needs are very complex • Multiple and overlapping child problem areas • Unmet basic family needs • Families are not engaged in treatment • Leads to treatment dropouts and missed opportunities

9. Child issues are often very complex 2004 Data N = 960 WRAPAROUND MILWAUKEE

10. Family Issues are often very complex 2004 Data WRAPAROUND MILWAUKEE: FAMILIES EXHIBITING CONCERNS n = 952

11. Families are not engaged in treatment • No show rates as high as 50% are common • Up to 60% of families drop out of services before they are finished • Kazdin et al., 1997 • Children from vulnerable populations are less likely to stay in treatment • Kazdin, 1993

12. The Research: Barriers to Involvement in Child Mental Health Interventions (Urban Settings) Triple threat: Poverty Stress Single Parenthood • Concrete obstacles: time, transportation, child care, competing priorities • Attitudes about mental health, stigma • Previous negative experiences with mental health or institutions

13. The Research: Barriers to Involvement in Child Mental Health Interventions (Rural Settings) • Scarce mental health resources • Transportation • Stigma associated with mental illness and seeking care • Concerns about confidentiality • Isolation

14. Some solutions to these problems • For families seeking help and entering treatment: Better engagement in the process and problem solving around barriers • For youth and families with very complex and overlapping needs: Care coordination (sometimes called Wraparound) • For all youth and families who would benefit: Parent/Youth Support and Advocacy

15. Empirically supported engagement interventions

16. Telephone Engagement Strategies to Address Barriers “First Telephone Contact”

17. Telephone Engagement Intervention Goals: 1) Clarify the need for mental health care 2) Increase caregiver investment and efficacy 3) Identify attitudes about previous experiences with mental health care and institutions 4) PROBLEM SOLVE! PROBLEM SOLVE! around concrete obstacles to care

18. First Session Engagement Process

19. 4 Basic Elements • Clarify the helping process for the client • Develop the foundation for a collaborative working relationship • Focus on immediate, practical concerns • Identify and problem-solve around barriers to help seeking

20. First Interview Study Methods • Outcome of interest: # of families that came to initial and ongoing appointments • Setting: Outpatient child mental health clinic • Sample: N=107 • Design: Random assignment to condition

21. First Interview Results

22. The Wraparound Care Coordination Process

23. Why Wraparound? • Intervening effectively with youth with complex emotional and behavioral disorders (EBD) has proven very difficult and outcomes have been poor. Why? • Child and family needs are complex • Youths with serious EBD typically have multiple and overlapping problem areas that need attention • Families often have unmet basic needs • Families are rarely fully engaged in services • Leads to treatment dropouts and missed opportunities

24. Why Wraparound? • Systems are in “siloes” • Special education, mental health, primary health care, juvenile justice, child welfare each are intended to support youth with special needs • However, the systems also have different philosophies, structures, funding streams, eligibility criteria, and mandates • These systems don’t work together well for individual families unless there is a way to bring them together • Youth get passed from one system to another as problems get worse • Families relinquish custody to get help • Children are placed out of home

25. What’s different in wraparound? • Big differences: “collaborative,” “family-driven,” “plan,” natural supports • Wraparound brings the systems together at the family level – Plans are designed and implemented by a team of people important to the family • The plan is driven by and “owned” by the family and youth • Strategies in the plan include supports and interventions across multiple life domains and settings (i.e., behavior support plans, school interventions, basic living supports, family supports, help from friends and relatives, etc) • Plans include supports for adults, siblings, and family members as well as the “identified youth”

26. For which children and youth is wraparound intended? • Youth with needs that span home, school, and community • Youth with needs in multiple life domains • (e.g., school, employment, residential stability, safety, family relationships, basic needs) • Youth for whom there are many adults involved and they need to work together well for him or her to succeed

27. Wraparound Process Principles • Family voice and choice • Team-based • Natural supports • Collaboration • Community-based • Culturally competent • Individualized • Strengths based • Unconditional • Outcome-based See the Resource Guide to Wraparound at www.wrapinfo.org for detailed descriptions

28. Wraparound:Principles are not Always Enough A review of wraparound teams showed that: • Fewer than 1/3 of teams maintained a plan with team goals • Fewer than 20% of teams considered >1 way to meet a need • Only 12% of interventions were individualized or created just for that family • Natural supports were represented minimally • 0 natural supports 60% • 1 natural support 32% • 2 or more natural support 8% • Effective team processes were rarely observed Walker, Koroloff, & Schutte, 2003

29. A practice model:The Four Phases of Wraparound Phase1A Engagement and Support Phase1B Team Preparation Phase2 Initial Plan Development Phase3 Implementation Phase4 Transition Time

30. Phase 1 A and B The Activities of Wraparound: Phase 1 Phase One: Engagement and Team Preparation • Meets with family & stakeholders • Gathers perspectives on strengths & needs • Assess for safety & rest • Provides or arranges stabilization response if safety is compromised • Explains the wraparound process • Identifies, invites & orients Child & Family Team members • Completes strengths summaries & inventories • Arranges initial Wraparound planning meeting

31. Phase 2 The Activities of Wraparound: Phase 2 Phase Two: Initial Plan Development • Holds an initial Plan of care Meeting • Introduces process & team members • Presents strengths & distributes strength summary • Solicits additional strength information from gathered group • Leads team in creating a mission • Introduces needs statements & solicits additional perspectives on needs from team • Creates a way for team to prioritize needs • Leads the team in generating brainstormed methods to meet needs • Solicits or assigns volunteers • Documents & distributes the plan to team members

32. Phase 3 The Activities of Wraparound: Phase 3 Phase Three: Plan Implementation & Refinement • Sponsors & holds regular team meetings • Solicits team feedback on accomplishments & documents • Leads team members in assessing the plan • For Follow Through • For Impact • Creates an opportunity for modification • Adjust services or interventions currently provided • Stop services or interventions currently provided • Maintain services or interventions currently provided • Solicits volunteers to make changes in current plan array • Documents & distributes team meetings

33. Phase 4 The Activities of Wraparound: Phase 4 Phase Four: Transition • Holds meetings • Solicits all team members sense of progress • Charts sense of met need • Has team discuss what life would like after Wraparound • Reviews underlying context/conditions that brought family to the system in the first place to determine if situation has changed • Identifies who else can be involved • Facilitates approach of “post-system” Wraparound resource people • Creates or assigns rehearsals or drills with a “what if” approach • Formalizes structured follow-up if needed • Creates a commencement ritual appropriate to family & team

34. When wraparound is implemented as intended… • High-quality teamwork and flexible funds leads to enhanced creativity, better plans, and better fit between family needs and services/supports • This in turn leads to greater relevance for families, less dropout • Strengths, needs, and culture discovery and planning process leads to more complete engagement of families • As family works with a team to solve its own problems, develops family members’ self-efficacy • Individualization and strengths focus enhances cultural competence, relevance, and acceptability • Focus on setting goals and measuring outcomes leads to more frequent problem-solving and more effective plans

35. Outcomes from Wraparound Milwaukee • After Wraparound Milwaukee assumed responsibility for youth at residential level of care (approx. 700-1000 per year)… • Average daily Residential Treatment population reduced from 375 placements to 70 placements • Psychiatric Inpatient Utilization reduced from 5000 days per year to under 200 days (average LOS of 2.1 days) • Reduction in Juvenile Correctional Commitments from 325 per year to 150 (over last 3 years) (Kamradt et al., 2008)

36. Results from Nevada:Impact on Residential Placement Bruns et al. (2006)

37. Results from Clark County, WAImpact on juvenile justice outcomes • Connections (wraparound) group (N=110) 3 times less likely to commit felony offense than comparison group (N=98) • Connections group took 3 times longer on average to commit first offense after baseline • Connections youth showed “significant improvement in behavioral and emotional problems, increases in behavioral and emotional strengths, and improved functioning at home at school, and in the community” Pullman et al. (2006)

38. Findings from a meta-analysis of seven controlled studies • Strong results in favor of wraparound found for Living Situation outcomes (placement stability and restrictiveness) • A small to medium sized effect found for: • Mental health (behaviors and functioning) • School (attendance/GPA), and • Community (e.g., JJ, re-offending) outcomes • The overall effect size of all outcomes in the 7 studies is about the same (.35) as for “evidence-based” treatments, when compared to services as usual (Weisz et al., 2005) Suter & Bruns (2008)

39. Wraparound in Washington • The wraparound process has been attempted in many projects in WA • Current projects include Three Rivers Wraparound (Benton-Franklin), CCS in Pierce County, several agencies in King Co. • Other projects (e.g., King County Blended Funding) were promising but ultimately de-funded • House Bill 1088 funded three wraparound pilots being overseen by MHD that began in 2008 and are being implemented in Skagit, Cowlitz, and Grays Harbor • King County plans to hire 30 new wraparound facilitators to serve 900 youth as part of its Mental Illness and Drug Dependency (MIDD) Strategic Plan • Yakima County has a new SAMHSA system of care grant that will be employing the wraparound care coordination process

40. Family Peer-to-Peer Support

41. Parent peer-to-peer support: One Definition • Parent-to-parent support is a consumer delivered service in which parents providing support have experiential knowledge (i.e., shared experiences) with the parent receiving support. • Parents providing support have shared similar experiences with those receiving support and were previously or are currently consumers of similar services. • Those utilizing consumer provided services report high satisfaction and perceived improvement for outcomes of satisfaction, quality of life, and social functioning • (Solomon & Draine, 2001).

42. Another definition(Keys for Networking, Topeka, KS) • Parent Support is an individually tailored service that connects a parent seeking help for a child with emotional, behavioral, or mental health issues with a trained and experienced peer who guides and coaches them to find their own strengths, define their own goals and needs, locate reliable information and resources, and develop their own voice to advocate on behalf of their child and family.

43. Parent peer-to-peer support:The theory base • Self-efficacy is the belief that one has the capabilities to manage prospective situations. For example, a person with high self efficacy may engage in a more health related activity when an illness occurs, whereas a person with low self efficacy would harbor feelings of hopelessness. • Bandura (1997) detailed four main sources from which individuals build self-efficacy: • Enactive mastery experiences (prior successful experiences) • Vicarious experiences (learning from others) • Verbal persuasion (understanding from peers) • Physiological and affective state (stress affects self-efficacy) • Parent-to-parent programs generally provide support in each of these areas. • Rivera et al., 2008

44. Family-based services: A review of the research (Hoagwood, 2005) • Studies that have been rigorously examined demonstrate unequivocal improvements in: • retention in services • knowledge about mental health issues • self-efficacy • family interactions. • “Linkage of effective family-based interventions to delivery of evidence-based services is likely to amplify the impact of those services and improve outcomes for youth and families.”

45. The Best Family/Youth Partners • Represent a perfect blend of who they are with what they can do, a mix between skill and personality. • Family/Youth Partner training gives parents/caregivers/youth a chance to practice skills and approaches to working with families, youth and professionals prior to doing the work.

46. CODE OF ETHICS • We tell our own story when it can help other families/youth. • We support other families/youth as peers with a common background and history rather than as experts who have all the answers. • We acknowledge that each family/youth’s answers may be different than our own. • We take responsibility for clarifying our role as Family/Youth Partners and as a parent of a child with special needs or a youth with special needs.

47. CODE OF ETHICS • We build partnerships with others including professionals who are involved in the care of children/youth. • We commit to honesty with each other and all involved with the care of a child/youth and expect the same from others. • We are committed to a non-judgmental and respectful attitude in our dealings with & discussions regarding families/youth. • We are committed to non-adversarial advocacy in our roles within systems.

48. COMMON TRAPS FOR FAMILY/YOUTH PARTNERS • Focus on access to service rather than access, voice, & ownership. • Becoming a traditional advocate. • Staying on the outside. • Choosing up sides. • Losing focus. • Forgetting the “long haul.”

49. OVERVIEW OF SKILL SETS • #1 Telling your own story when it can help others. • #2 Supporting families/youth as peers rather than as experts with all of the answers. • #3 Acknowledge each family/youth’s answers are different. • #4 Clarify role as a family/youth partner & parent/caregiver of a child with special needs or a youth with special needs.

50. SKILLS (Cont.) • #5 Building partners with others including professionals. • #6 Committing to honesty in self & others. • #7 Committing to non-Judgmental & respectful attitude. • #8 Providing non-adversarial advocacy.