Researching Wraparound in Nevada Overview of the “Youth and Family Supports Study” Funded by the National Institute of M

1. Researching Wraparound in NevadaOverview of the “Youth and Family Supports Study”Funded by the National Institute of Mental Health State MH Consortium Meeting May 22, 2008 Reno, Nevada Eric J. Bruns, University of Washington Ramona Denby Brinson, University of Nevada, Las Vegas Michelle Ramey, University of Nevada, Las Vegas ebruns@u.washington.edu Ramona.denby@unlv.edu Michelle.Ramey@unlv.edu

2. Overview of this Presentation • Background: What works in children’s mental health? • The role of Wraparound in achieving positive outcomes for youth and families • What does it take to implement wraparound? • Research on “wraparound fidelity” • The Nevada Youth and Family Supports Study • Study goals • Data still to come • Opportunities for Nevada • Data from the Study so far: Implementation of Wraparound in Nevada • What next?

3. What is an “Evidence Based Practice”? • A process of applying scientific knowledge about service practices to the situation of an individual child and family • Treatment procedures that have been shown to be effective through scientific evidence of some level of robustness* *From Bruns, Hoagwood et al. (in press). State implementation of evidence based practice, Part 2: Recommendations for research and policy. Journal of the American Academy of Child and Adolesc. Psychiatry.

4. 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…

5. Unfortunately, major barriers to using EBPs in “real world” practice • Complexity of child and family needs • Multiple and overlapping child problem areas • Unmet basic family needs • Many providers, many requirements, little coordination • Lack of full engagement and partnership with families • Families are overwhelmed, do not feel their priority needs are being addressed • Leads to treatment dropouts, missed opportunities for positive change, bad outcomes

6. Theory of change: Why wraparound may be critical to positive outcomes Facilitator, Team, Flex funds, Service array Getting Support Positive Achieving Goals Teamwork & coordination Family Drives the process Optimism & Hope Better plans Better follow through Self- Efficacy Outcomes! Natural supports

7. Promising Outcomes for Communities using the Wraparound Process

8. Outcomes – Wraparound Milwaukee • 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)

9. Results from Nevada:Living in less restrictive, more community based settings

10. Results from Nevada:Functioning better in the community

11. Results from Oklahoma:Getting to permanency

12. Results from OklahomaSupporting re-integration of adult prisoners

13. OK, so the “theory of change” makes good sense. Families like wraparoundThe model is being better understood. The research base continues to grow…So, what is the challenge?

14. Less than 1/3 of teams maintained a plan with team goals Less than 20% of teams considered >1 way to meet a need Only 12% of interventions were individualized or created just for that family All plans (out of more than 100) had psychotherapy 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 A National Reviewof Wraparound Teams Showed(Walker, Koroloff, & Schutte, 2003)

15. Hospitable System (Policy and Funding Context) Supportive Organization (lead and partner agencies) Effective Team

16. System and organizational supports for wraparound • Community Partnership. Community ownership of wraparound is built through collaborations among key stakeholder groups. • Collaborative Action. Stakeholders involved in the wraparound effort take concrete steps to develop concrete policies, practices and achievements. • Fiscal Policies and Sustainability. The community has developed fiscal strategies to meet the needs of children participating in wraparound and methods to collect and use data on expenditures.

17. System and organizational supports for wraparound • Access to Needed Supports & Services. There are mechanisms for ensuring access to the services and supports that teams need to fully implement their plans • Human Resource Development & Support. The system supports wraparound staff and partner agency staff to fully implement the wraparound model. • Low caseloads • The right job descriptions • Training and coaching • Good supervision, etc • Accountability. The community has mechanisms to monitor wraparound quality and outcomes.

18. Monitoring quality of implementation of child and family teams • Have facilitators and team members fill out activity checklists • Look at plans of care and meeting notes • Sit in on and observe team meetings • Ask the people who know– parents, care givers, youth, facilitators, program heads

19. Wraparound Fidelity Assessment System TOM – Team Observation Measure WFI-4 – Wraparound Fidelity Index WFAS WFI-4 TOM Doc Review CSWI CSWI – Community Supports for Wraparound Index DOC - Document Review Measure

20. Summary: What Leads To Outcomes? Program and System Supports Sticking to the wrap principles in service delivery Improved Child and Family Outcomes Training, Coaching, and Quality Assurance

21. A summary of research on wraparound implementation • There are connections between system support for wraparound implementation and fidelity • There are connections between wrap fidelity and child and family outcomes • We are beginning to get a sense of what “high” fidelity is in terms of scores on tools like the WFI • BUT: The research is still preliminary, and the field is looking for additional evidence

22. Studying Wraparound Implementation in Nevada

23. The “Outcomes of Wraparound in Nevada” Study • The first NIMH-sponsored controlled research study of wraparound • Examines the differences in outcomes, treatment processes, and costs of wraparound vs. case management • Tests psychometrics of the Wraparound Fidelity Index and other fidelity tools • A chance to use data on treatment processes, costs, and outcomes to inform implementation of services for youth with SED in Nevada

24. Major Research Questions • Does implementing wraparound for a youth with SED result in a different service process than implementing intensive CM? • Does the wraparound process lead to better outcomes? • What are the costs of the two models? • How important is “wraparound fidelity” to achieving outcomes?

25. Study population • 150 children and youth (age 6-17) with SED that requires intensive intervention • Fee for service Medicaid eligible • N=75 assigned to Wraparound condition as delivered by WIN and CCS • N=75 assigned to CM delivered by Mojave

26. What data is the Youth and Family Supports Study providing? • Child Behavior and Functioning • Strengths and Difficulties Questionnaire (SDQ) • Child and Adolescent Functional Assessment Scale (CAFAS) • Child Status Report – Residential Setting; Child Welfare, School, and Juvenile Justice Outcomes* • Services received • Services Assessment for Children and Adolescents • Case Management Function Form • Service processes and satisfaction • Parent and Youth Satisfaction Questionnaires • Working Alliance Inventory • Family Empowerment Scale • Glisson Organizational Social Context Scale * Also being collected via admin. data from DCFS, DJJS, CCPSS

27. Additional data from the Youth and Family Supports Study • Fidelity to the wraparound model • From interviews of the WFI • From team observations from the TOM • System support for wraparound • Community Supports for Wraparound Inventory (CSWI) • Connections to resources – who is on their team? What is in their plan? • Whether services are making a difference in areas that matter to families (e.g., optimism; level of empowerment; lost days at work)

28. Progress report

29. Study Enrollment to date

30. Characteristics of YFSS Participants N=48 total (41 active) cases with baseline data collection completed as of April 2008

31. Demographics • Male = 22 (46%) • Female = 26 (54%) • Age • Mean = 11.42 (SD = 3.35) • Range = 6-17 • Race • African American = 16 (36%) • White = 12 (27%) • Hispanic = 7 (16%) • Mixed Race = 7 (16%) • AA & White = 3; AA & Hispanic = 4 • Native American = 1 (5%) • Biological parents w/parental rights = 15 (31%)

32. Referral and study information • Referral source (to services) • Child welfare = 37 (79%) • Self = 7 (15%) • School = 2 (4%) • Mental health agency/provider = 1 (2%) • Language spoken at home (other than English) • Spanish = 2 (4%) • Assignment to services • ICM = 20 • WIN = 20 • CCS = 8

33. Placement and Placement History • Current placement • Foster Care = 18 (44%) • Biological or Adoptive Parents = 11 (27%) • Group Home or Shelter = 5 (12%) • Relative = 5 (10%) • Residential job corps/vocational = 2 (5%) • Previous 6 mos • Group Home or Shelter Care = 8 (20%) • Residential Treatment = 4 (10%) • Psychiatric Hospital = 3 (7%)

34. DSM Diagnoses assigned (N=30) • Adjustment Disorders = 10 (33%) • ADHD = 8 (26%) • Mood Disorders (incl. Depression/Bipolar) = 7 (22%) • Disruptive disorders (incl. ODD/CD) = 7 (22%) • Post Traumatic Stress = 4 (13%) • Attachment Disorders = 2 (7%) • Developmental Disorders = 2 (7%) • Substance Abuse Disorder = 1 (3%) • Learning Disorder = 1 (3%) • Psychotic Disorder = 1 (3%)

35. Number of Diagnoses Assigned (N=30)

36. CAFAS Functioning Subscales:Percent of youth with “moderate to severe” needs

37. Findings on Wraparound Implementation in Nevada from the YFSS

38. Baseline Fidelity data assessment (2006-07) • Vision for the project: • Inform high quality practice, • Create a culture in which data is used to inform decision making, • Ensure a better understanding of wraparound on the part of families and providers, and • Help “make the case” for better support for wraparound implementation in Nevada.

39. Baseline Fidelity data assessment (2006-07) • Methods: • Random sample of N=90 youth drawn from WIN and CCS in Clark Co • Data collection completed for: • Wraparound Fidelity Index (WFI) • N=59 youth • 139 interviews completed across the 3 respondent types • Team Observation Measure (TOM) • N=27 team meetings observed by UNLV and DCFS staff • Document Review Measure (DRM) • N=65 case files reviewed by UNLV and DCFS staff

40. Results of Fidelity Assessment:Strengths of wraparound implementation • Cultural & Linguistic Competence. • WIN and CCS teams have shown respect for the values, preferences, beliefs, culture, and identity of the child and family, and their community. Items for this indicator were extremely high across all instruments used. • Collaborative Efforts. • Those serving on WIN and CCS wraparound teams demonstrate cooperation and shared responsibility for developing, implementing, monitoring, and evaluating wraparound plans. • In particular, effective team brainstorming of strategies was noted in the WFI. • Persistence. • Data indicate WIN and CCS wrap teams persist in working towards goals included in the wraparound plan, despite challenges presented by enrolled families. • Teams successfully maintain youth in the community, and ensure some members of the team will be available after formal wraparound is finished. • Other strengths • Working to keep the youth in the least restrictive environment, encouraging youth and family voice, maintaining a positive team culture and having team members who share responsibility for designing and implementing the child and family’s plan

41. Results of Fidelity Assessment:Needs for improvement • Natural Supports. • Seeking out and encouraging full participation of individuals from family members’ networks of interpersonal and community relationships. • Team Based. • The family and youth are not typically picking who will be on their child and family team, and there are unclear roles for natural & community supports on teams. • Outcome Based Process. • WIN and CCS wrap teams are not consistently tying the goals and strategies of the wraparound plan to measurable indicators, measuring progress, using assessment of progress to guide follow-through. • Crisis Planning. • Many records did not include crisis plans that based on functional assessments for the children and youth and did not have strategies for preventing the crisis or detailed steps to be taken. • Other needs for improvement • Strategizing ways to involve the youth and family in community activities • Transition planning • Clarity of roles between DCFS and child welfare staff

42. Summary scores: Wraparound Fidelity IndexCompared to another state + “high fidelity” benchmarks

43. More Results on Wrap Implementation: From the Community Supports for Wraparound Inventory

44. The Community Supports for Wraparound Inventory • The 40 items are grouped within 6 themes: • Community partnership • Collaborative action • Fiscal policies • Service array • Human resource development, and • Accountability • Respondents complete the 40 items by rating the development of supports in their community or program on a 5 point scale • 0 = “least developed” and 4 = “fully developed”

45. Method • 31 stakeholders in the Nevada system of care were identified and invited to complete the CSWI • These stakeholders were sent a link to a web survey version of the CSWI • 22 nominated respondents completed the CSWI (71%), 4 declined to complete the CSWI (13%), and 5 did not respond (16%)

46. Respondents Mean total experience with wraparound = 6.6 years Mean years in current wrap program = 3.6 years

47. Respondents: Experience by Role in Wraparound Implementation *This column total sums to more than total respondents due to people having filled multiple roles over time.

48. CSWI Results: Averages by Theme for NV Least developed Fully developed Midway

49. Cross-Site Comparison:Nevada (site 2) versus 5 other Wrap initiatives

50. Results • Greatest relative strength**