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

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


1
A Roadmap to Transformation Innovations,
Perspectives, and Partners for Action
  • Evidence-Based Practices
  • for
  • Children, Adolescents their Families

2
GOALS OF SESSION
  • National Overview of Evidence Based Practices
  • Implementation of MST and FFT
  • Importance of Family Voice
  • Questions Answers

3
  • Above All,
  • Do No Harm…
  • Hippocrates

4
  • …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)

5
  • 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)

6
"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)
7
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)

8
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

9
STRONGEST POSITIVE 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)

10
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)

11
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

12
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

13
(No Transcript)
14
TRANSFORMATION
15
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)

16
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)

17
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

18
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)

19
Kevin Campbell, KevinC_at_ccsww.org 253-225-0988
20
You never change things by fighting existing
reality. To change something, build a new
model that makes the old model obsolete.
  • - Buckminster Fuller

21
CONTACT INFORMATION
  • Beth Caldwell
  • Caldwell Management Associates
  • 413-644-9319
  • bethcaldwell_at_mailcity.com

22
Olmstead Conference Lessons Learned from Ohio
  • Patrick Kanary
  • Center for Innovative Practices
  • www.cipohio.org

23
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.

24
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

25
Center for Innovative Practices Objectives
  • 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

26
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

27
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

28
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

29
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)

30
Ecological Model
Community/Culture
Neighborhood
School
Peers
Family
Child
31
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)

32
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

33
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

34
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

35
Why Stakeholders Care about Effective Practices
  • Funders
  • Consumers and Families
  • Providers
  • Policy Makers

36
Funders
  • Limited resources need to be maximized
  • Cost effectiveness
  • Redirecting funds from services that are not
    effective refinancing
  • Outcomes

37
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

38
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

39
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

40
Reality Considerable Challenges
  • Financial
  • Clinical
  • Systemic

41
Clinical Challenges
  • Changing practices for both clinicians and
    organizations
  • Rigorous supervision/coaching ongoing training
  • Focus on Quality Improvement and Assurance
  • Staffing

42
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 scale…making effective practices the rule

43
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

44
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

45
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

46
Elements for Success
  • Service development based on data driven needs
    assessment what can and will the local system
    support
  • Investment in Practice Based Evidence…documentin
    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

47
Location! Location! Location!
  • All politics are local.
  • All Evidence Based Practice implementation is
    local.

48
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

49
Contact Info
  • Patrick J. Kanary, Director
  • Center for Innovative Practices
  • patrick_at_cipohio.org
  • 216-371-0113
  • WWW.CIPOHIO.ORG

50
Implementing Evidence Based Treatments
  • One States Experience with FFT
  • Michael Bigley
  • New York Office of Mental Health

51
What is Functional family Therapy ? - A treatment
technique
52
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

53
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

54
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

55
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

56
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

57
Anecdotal Evidence
  • Site Histories
  • Therapist success
  • Case Histories
  • Testimonials
  • Legacy families
  • Reports from Probation
  • Suffolk County
  • Ulster county

58
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

59
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

60
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

61
Olmstead Conference The Importance of Family
  • Euphemia Strauchn
  • Childrens Services Initiative
  • Mental Health Association of NYC, Inc.

62
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.

63
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.

64
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

65
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

66
Communicating With Families
  • Empathy is important
  • Use good listening skills
  • Communicate clearly
  • Dont assume, ask questions
  • Remember
  • Body language speaks louder than words!

67
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

68
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

69
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

70
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 (212) 964-5253 ext. 756
  • Cell (917) 657-2764
  • Email EStrauchn_at_mhaofnyc.org or
  • Euphemia615_at_aol.com
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