A Roadmap to Transformation: Innovations, Perspectives, and Partners for Action

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A Roadmap to Transformation Innovations,
Perspectives, and Partners for Action

• Evidence-Based Practices
• for
• Children, Adolescents their Families

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GOALS OF SESSION

• National Overview of Evidence Based Practices
• Implementation of MST and FFT
• Importance of Family Voice
• Questions Answers

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• Above All,
• Do No Harm
• Hippocrates

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• Evidence-Based Practices (EBPs) are
  interventions for which there is consistent,
  scientific evidence showing that they improve
  consumer outcomes
• (NYS OMH, 2005)
• "Evidence-based practices are interventions for
  which there is consistent scientific evidence
  showing that they improve client outcomes."
• (Drake et al., 2001)
• (http//nri-inc.org/CMHQA.cfm)

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• Evidence-based practices are skills, techniques,
  and strategies that can be used by a
  practitioner. Such practices describe core
  intervention components that have been shown to
  reliably produce desirable effects and can be
  used individually or in combination to form more
  complex procedures or programs (Embry, 2004).
• (NIRN, FMHI, USF, 2005)

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"Evidence-based practice is the integration of
best research evidence with clinical expertise
and patient values......Patient values refers to
the unique preferences, concerns, and
expectations that each patient brings to a
clinical encounter (Crossing the Quality Chasm,
Institute of Medicine, 2001, p. 147)
(http//nri-inc.org/CMHQA.cfm)
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Common Elements of Evidence Based Programs

• Clear philosophy, beliefs, and values
• Specific treatment components (treatment
  technologies)
• Treatment decision making (within the program
  framework)
• Structured service delivery components.
• Continuous improvement components
• (NIRN, FMHI, USF, 2005)

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CRITERIA (http//nri-inc.org/CMHQA.cfm)

• SAMHSAs NREP Promising Effective Model
• The American Psychological Association
• Cochrane Collaboration
• Campbell Collaboration
• The Society for Prevention Research
• Center for the Study and Prevention of Violence
• The Hawaii Department of Health - Child and
  Adolescent Mental Health Division
• Oregon EBP Model

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STRONGESTPOSITIVE OUTCOMES FOR CHILDREN WITH
SED FAMILIES

• Home-based services, including Multi-systemic
  Treatment
• Therapeutic foster care, including Multidimension
  Treatment Foster Care
• Case management
• Cognitive-behavioral therapies for some disorders
• Pharmacotherapy for some disorders
• Specific family educational or supportive
  interventions, including Functional Family
  Therapy
• (NYS OMH, 2005)

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States required to report to NRI on
implementation of the following three EBPs

• Multi-systemic Treatment
• Functional Family Therapy
• Therapeutic Foster Care (i.e. Multidimension
  Treatment Foster Care)

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SEVERAL STATES WITH SPECIAL EBP FOCUS

• Ohio Research on Agency Readiness
  RothD_at_mh.state.oh.us
• New Mexico Medicaid for MST kens.warner_at_state.nm.
  us
• Oregon Hawaii Approval Process for EBPs
  http//egov.oregon.gov/DHS/mentalhealth/ebp/ebp-li
  st cmdonker_at_camhmis.health.state.hi.us
• California County based penny.knapp_at_dmh.ca.gov
• Minnesota Delaware Medicaid Mental Health
  Transformation Grants for EBPs peggy.clark_at_cms.hhs
  .gov

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HELP SUPPORT W/ EBP

• National Research Institute www.nri-inc.org
• Chart of EBP Implementation by State
• Implementation Tool Kit (in development)
• Resource Guide for Children Families (in
  development)
• Center for Advancement of Childrens Mental
  Health www.kidsmentalhealth.org
• Training Institute for Evidence-based (NYC 10/05)
• National Implementation Research Network
  www.nirn.fmhi.usf.edu
• Implementation Support

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TRANSFORMATION
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Blueprint for New Treatment Development

• Clinic/Community Intervention Development Model
• 8 steps ranging from theoretical and clinically
  informed construct to initial efficacy trial
  under controlled conditions to single case
  application in practice setting to full test and
  test of different variations and assessment and
  dissemination
• (Burns, 2003)

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PRACTICE BASED EVIDENCE

• Research shows the first three client contacts
  account for a majority of the Outcome
• Relationship factors account for 55 of
  successful outcomes
• Agreed upon Goals
• Agreed upon Objectives to meet Goals
• Ability to develop an empathetic relationship
• Client strengths account for 40
• (Arizona DBHS, SW Behavioral Health Services,
  2005)

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Emerging Positive Practices

• Trauma Informed Care (NASMHPD/NTAC, 2005)
• Executive Skill Functioning (Greene, 2005)
• NETI/NTAC Core Strategies for Reducing Coercive
  Interventions (NASMHPD/NTAC, 2005)
• Focus on Permanency KevinC_at_ccsww.org

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One child program where R/S reduced by 88 over 3
years

• ALOS
• Hours spent on Treatment from 76.7 to 95.5
• 52 in discharges occurring w/ admission
  treatment goals attained
• 92 vs 75 of success at less restrictive level
  of care at 6 months post discharge
• 98 reduction in staff days missed at work
• 52 reduction in sick time
• 83.3 reduction in staff turnover
• 30 reduction in workman's comp claims
• 98 reduction in paid compensation medical
  costs paid (Lebel, 2005)

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Kevin Campbell, KevinC_at_ccsww.org 253-225-0988
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You never change things by fighting existing
reality. To change something, build a new
model that makes the old model obsolete.

• - Buckminster Fuller

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CONTACT INFORMATION

• Beth Caldwell
• Caldwell Management Associates
• 413-644-9319
• bethcaldwell_at_mailcity.com

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Olmstead ConferenceLessons Learned from Ohio

• Patrick Kanary
• Center for Innovative Practices
• www.cipohio.org

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As the Journey Begins

• Turbulence is life force. It is opportunity.
  Let's love turbulence and use it for change.
• Ramsay Clark
• OR
• as Bette Davis would have said
• Fasten your seat belts, it is going to be a bumpy
  ride.

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Center for Innovative Practices

• Created by ODMH as part of its Coordinating
  Centers of Excellence InitiativeCCOE
• CCOEs across the state focusing on several
  treatment and/or population specific areas
  MH/CJ Illness Recovery and Management MH/MRDD,
  SAMI

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Center for Innovative PracticesObjectives

• To identify and promote the use of specific
  evidence based behavioral interventions (e.g.,
  MST) for youth and their families
• To develop partnerships and affiliations with
  EBP-BP developers and other relevant
  organizations in order to implement strategies
• Increase awareness of and access to EBP
• Assist communities in development of EBP
• To participate in state and local program and
  policy discussions recommendations

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Transformation Implications Using a Center of
Excellence Model

• An identifiable entity (tool) that is accessible
  to stakeholders
• Use real world experience to prepare the field
• Identify the active transportability elements
  that best prepare the field, regardless of the
  specific practice
• Gains and shares knowledge both academically and
  pragmatically
• Source of good information, reliable, trustworthy
• Understands and spans the boundaries among
  stakeholders

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Initiatives

• Multisystemic Therapy
• Intensive Home and Community Based Services
• Wrap Around
• Integrated Co-Occurring Treatment
• Mental Health Services to Juvenile Offenders
• Resilience
• Access to Better Care
• Technical assistance related to evaluation and
  research

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Lessons from MST and other Practices

• Implementation of MST has provided us our
  strongest base of Lessons Learned
• CIP is a licensed Network Partner of MSTServices,
  Inc.
• CIP provides all aspects of development and
  implementation of MST in Ohio
• 2 full time MST Consultants
• 9 Providers with 12 teams in 13 counties
• Presentations and dissemination of information
• Support to local communities to develop MST
  programs

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MST Theoretical Assumptions
Based on Bronfenbrenner, Haley , and Minuchin

• Children and adolescents live in ecologies or
  systems that impact their behaviors in direct and
  indirect ways
• These influences act in both each directions
  (they are reciprocal and bi-directional)

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Ecological Model
Community/Culture
Neighborhood
School
Peers
Family
Child
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How does MST work

• Intervention strategies MST draws from
  research-based treatment options
• Behavior therapy
• Cognitive behavior therapy
• Pragmatic family therapies
• Structural Family Therapy
• Strategic Family Therapy
• Pharmacological interventions (e.g., for ADHD)

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How does MST work (continued)

• Context for use of evidence-based intervention
  strategies
• Services are comprehensive, individualized and
  address all identified drivers of the problem
  behaviors
• MST program philosophy emphasizes that service
  providers are accountable for outcomes
• Families and communities are central and
  essential partners in MST treatmentand
• Caregivers/parents are key to long-term success
• Program structure removes barriers to service
  access

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How is MST implemented?

• Single Therapist working intensively with 4 to 6
  families at a time
• 4 months is the typical treatment time
• Work is done in the community home, school
  neighborhood, etc.
• MST staff deliver all treatment
• MST staff take a lead role in clinical decision
  making for each case

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Cost Effectiveness of MST

• Washington State Institute of Public Policy
  (2001)
• Research to identify ways to lower crime and
  lower total costs to taxpayers and crime victims
• Detailed evaluations of 14 programs/program
  types
• Program Rank Net
  taxpayers savings
• MST 1 31,661 to 131,918/youth
• Treatment Foster Care 2 21,836 to 87,622
• Functional Family Ther 3 14,149 to 59,067
• Scared Straight Programs 14 - 6,572 to -24,531

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Why Stakeholders Care about Effective Practices

• Funders
• Consumers and Families
• Providers
• Policy Makers

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Funders

• Limited resources need to be maximized
• Cost effectiveness
• Redirecting funds from services that are not
  effective refinancing
• Outcomes

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Consumers and Families

• Expectation of access to effective services
• Focus on real world outcomes as measures of
  success
• Family strength approach and engagement
• Often intersystem or ecological in operation
• Outcomes

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Providers

• Deliver quality services to their consumers
• Leading edge of progress in the system
• Funding sources are requiring EBP/BP
• System moving to outcome based
• Opportunity to enhance service array
• Outcomes

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Policy Makers

• Consistent with good public health practice
• Strategy to link public serving systems together
• Meets common goals of multiple systems
• Strengthens relationship to research and
  evaluation activities
• Responds to a growing demand and expectation by
  consumers and families
• Outcomes

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Reality Considerable Challenges

• Financial
• Clinical
• Systemic

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Clinical Challenges

• Changing practices for both clinicians and
  organizations
• Rigorous supervision/coaching ongoing training
• Focus on Quality Improvement and Assurance
• Staffing

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Systemic Challenges

• The allure of the list
• Identifying and selecting practices within a
  context of a community planning process
• Shift to an outcomes based (qualitative) system
  of care
• Developing local evaluation capacity
• Going to scalemaking effective practices the rule

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Financial Challenges

• Bridge funding to finance start up Wheres the
  money?
• Anticipating all the costs
• Mechanics of reimbursement and limitations of fee
  for service
• Potential conflict with productivity approach

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Factors that Inhibit Development

• Perceived over-promise of the intervention
• Lack of adequate advance strategic planning
• High level of resistance to change
• Workforce issues
• Short term plan for financing

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Factors that Facilitate Development

• EBP within framework of SOC
• Parents and youth are partners and represented
• Identifiable outcomes for multiple systems
• Flexible funding
• Risk takers and boundary spanners, particularly
  at the local level

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Elements for Success

• Service development based on data driven needs
  assessment what can and will the local system
  support
• Investment in Practice Based Evidencedocumentin
  g effectiveness
• Real world data to capture clinical and cost
  effectiveness
• Diversion from more costly, more restrictive
  level of care
• The more complex and challenging the targeted
  need area, the higher the need for strong,
  effective services

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Location! Location! Location!

• All politics are local.
• All Evidence Based Practice implementation is
  local.

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Thanks To

• Jane Timmons-Mitchell, CIP
• Keller Strother, MST Services
• Lynne Marsenich, California Institute for MH
• Annapolis Coalition material
• Karen Blasé of the National Implementation
  Research Network
• Lots of others

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Contact Info

• Patrick J. Kanary, Director
• Center for Innovative Practices
• patrick_at_cipohio.org
• 216-371-0113
• WWW.CIPOHIO.ORG

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Implementing Evidence Based Treatments

• One States Experience with FFT
• Michael Bigley
• New York Office of Mental Health

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What is Functional family Therapy ?- A treatment
technique
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Why Functional Family therapy

• Designed for behaviorally disruptive 11-18 year
  olds
• 80 successful completion rate
• Short Term Treatment 8 to 12 visits
• Medicaid eligible as a clinic service
• In-clinic or in-home service
• Direct and collateral visits
• Sustainable after training

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What We Did

• Met with provider agencies to determine interest
• Met with clinicians to orient them to FFT
• Trained 15 multi-agency teams in 4 geographic
  areas in 3 months
• Lost 3 teams in the first 3 months
• Lost a total of 7 teams in the first year
• Redesigned our selection and implementation
  process

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What We Have Learned

• Agencies and therapists must be prepared to
  adhere to the model rather than participate to
  become better family therapists
• Pre implementation planning must involve all
  levels of the agency to assure proper
  implementation and support
• Planning needs to include a realistic view of
  referral volume
• The referral process needs to be defined and
  monitored to assure adequate numbers of referrals

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What We Did Next

• Met with provider agency leadership to discuss
  specifics on target population, program goals,
  and support for clinical staff
• Met with middle management to discuss current
  agency programs, use of staff and anticipated
  changes.
• Met with clinicians to discuss FFT as a
  restrictive model

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Problems Identified

• Multi agency implementation is difficult common
  problems but unique solutions
• Part-time FFT is difficult
• Maximum caseloads make it difficult to maximize
  income
• Lack of local program advocacy restricted
  referrals to the point of program failure

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Anecdotal Evidence

• Site Histories
• Therapist success
• Case Histories
• Testimonials
• Legacy families
• Reports from Probation
• Suffolk County
• Ulster county

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New York State Results

• 1400 children and families served
• 70 of cases closed
• 61 of children continued through eight or more
  sessions
• High level of agreement between children and
  parents on improvement
• ratings show statistically reliable positive
  change from the dysfunctional to the normal
  range.
• The most noticeable change occurred in the area
  of parental supervision

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Current Strategies

• Focus on smaller single agency teams
• Advertise and advocate for the program
• Expand programs to other agencies populations
• Become full-time FFT through multi agency funding
  and referrals
• Maintain support for model fidelity, ongoing
  support and training

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Contact Info

• Michael F. Bigley, MSS, ACSW
• Senior Program Specialist
• Division of Children and Families
• NYS Office Of Mental Health
• mbigley_at_omh.state.ny.us
• 518 474-4039

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Olmstead ConferenceThe Importance of Family

• Euphemia Strauchn
• Childrens Services Initiative
• Mental Health Association of NYC, Inc.

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FAMILY PERSPECTIVE

• The effectiveness of services provided to
  children and youth who have emotional,
  behavioral, and mental health challenges impacts
  their entire family everyday of their lives. By
  engaging families as equal partners in system of
  care service delivery, families have a voice, and
  are more likely to receive services that they
  will utilize.
• Engaging families in system of care service
  delivery is accomplished in part by involving
  families in decision making processes such as the
  development of family plans, treatment plans, the
  assessment of services, and as stakeholders in
  focus groups for program enhancement or
  development.

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Family Perspective First Impressions Count

• The first impression that a family has of an
  agency or worker can impact the level of
  involvement of that family, or determine if they
  will accept the services provided.
• The first impression that a worker or agency has
  about a family can impact the level of engaging
  that family, and or the quality of services
  provided.
• Remember
• Sometimes the first encounter is the only
  opportunity that you will have.

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Working with the Family (Strength Based Approach)

• Families have a voice
• Families have options
• Families feel respected
• Families are met where they are at
• Family members are equal partners / collaborators
• Families are humanized
• Needs of the family are met (demand and supply)
• Those receiving services are referred to as
  families

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Building Respectful Relationships with Families

• Include families in the decision making process
• Keep it real
• Share information
• Language is everything - terminology makes a
  difference
• Remember
• Perception Expectation Assumption Outcome

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Communicating With Families

• Empathy is important
• Use good listening skills
• Communicate clearly
• Dont assume, ask questions
• Remember
• Body language speaks louder than words!

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Cultural and Linguistic Competency

• Provide written materials in the primary language
  spoken by the family
• Expand understanding of the historical
  experiences other cultures
• Have pictures, magazines etc. that reflect the
  families and communities served in waiting areas

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Ongoing Assessment

• Check in with the families periodically about
  service delivery
• If the original plan developed with the family is
  not working, do not give up on the family, change
  the plan

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Moving Forward Successfully

• Remember
• Families that we work with have a wealth of
  experience to share
• Engaging families in decision making is
  empowering to families
• Engaging families requires building relationships
  that enable us to trust each other through the
  process

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Contact Information

• Euphemia Strauchn, MSW, FDC
• Co-Project Director /
• Lead Family Member Representative
• Mental Health Association of NYC, Inc.
• Coordinated Childrens Services Initiative of
  NYC (CCSI)
• 157 Chambers Street, 9th Floor
• New York, NY 10007
• Office [phone] ext. 756
• Cell [phone]
• Email EStrauchn_at_mhaofnyc.org or
• Euphemia615_at_aol.com