The HOMEBUILDERS

1
The HOMEBUILDERS Model What We Have Learned
Over the Last Thirty Years

• Shelley Leavitt, Ph.D.
• Institute for Family Development

2
What is Homebuilders?

• Homebuilders is an intensive in-home family
  treatment program designed to keep children and
  families safe and prevent the unnecessary out of
  home placement of children, and to safely reunify
  children and families.

3
Homebuilders Program Philosophy

• It is best for children to be raised
• in their own families whenever
• possible.

4
Applications of the Homebuilders Model

• Placement Prevention
• Reunification
• Adoption and Long-Term Foster Care Stabilization

5
Program Model
Intervention Activities
Program Structure
Values and Beliefs
6
Homebuilders Program Structure Values Based
Orientation

• The Homebuilders model is based on a clearly
  articulated set of values and beliefs, which
  guides program design and staff behavior.

7
HomebuildersValues and Beliefs

• Safety is our highest priority
• We cannot predict which situations are most
  amenable to change
• A crisis is an opportunity to change
• It is our job to motivate clients and instill
  hope
• Family members are our partners
• We can make life worse for families

8
HomebuildersValues and Beliefs (Continued)

• Children can be brought up in different kinds of
  families
• People are doing the best they can
• It is our basic job to empower family members
• It is helpful for us and the family to think of
  ourselves as personal scientists
• It is important to minimize barriers to service

9
Homebuilders Program Components

• Program Components are designed to minimize
  barriers to service
• Focus on a Specific Target Population-Children
  at imminent risk of out of home placement and
  children in placement who are at the point of
  reunification
• Immediate Availability and Response to Referrals-
  Referrals are accepted 24 hours a day, 7 days a
  week. The Homebuilders therapist meets with the
  family as soon as possible and no later than 24
  hours after the referral is received

10
Homebuilders Program Components

• Services Provided in the Natural Environment
  Primarily in the home and in the community where
  the problems occur
• Intensive Services Average of 8-10 face to face
  hours/week
• Brevity of Services Average of 4-6 weeks
  extensions and booster sessions
• Low Caseload Average 2 families

11
Homebuilders Program Components

• Twenty-Four Hour a Day Availability to Clients
  Primary therapist and supervisor available to
  families 24/7
• Single Therapist Operating within a Team -
  Assures consistency, enhances engagement,
  minimizes duplication of services and increases
  accountability

12
Homebuilders Program Components

• Supervision and Consultation Supervisor
  available 24/7 weekly individual and group
  consultation
• Accountability Goal oriented interventions,
  evaluations of outcomes, family and referring
  worker feedback
• Ongoing Training and Quality Enhancement (QUEST)

13
Homebuilders Intervention Activity Promoting
Safety

• Throughout the intervention, the therapist
  assesses child, family, therapist and community
  safety and develops safety plans, structures the
  environment and uses clinical strategies to
  promote safety.

14
Homebuilders Intervention Activity Individually
Tailored Services

• Services and teaching strategies are tailored
  to the familys needs, goals, values, learning
  styles and specific circumstances. The therapist
  flexibly schedules sessions with family members,
  based on the familys schedule and situation.

15
Homebuilders Intervention Activity Engagement
and Motivation Enhancement

• The therapist develops and maintains a positive,
  collegial working relationship with family
  members and assumes responsibility for motivating
  the family.

16
Homebuilders Intervention Activity Comprehensive
Assessment

• The therapist conducts a behaviorally specific,
  interactive, ongoing, and holistic assessment,
  which includes information on family strengths,
  problems, needs, values, skills and potential
  barriers to goal attainment.

17
Homebuilders Intervention Activity Goal Setting
and Service Planning

• The therapist collaborates with family members
  and referring workers in developing behaviorally
  specific, attainable intervention goals and
  service/treatment plans.

18
Homebuilders Intervention Activity Cognitive and
Behavioral Approach

• The Homebuilders therapist utilizes
  research-based cognitive and behavioral
  intervention strategies to facilitate behavior
  change in children, youth and parents/caregivers.

19
Homebuilders Intervention Activity Teaching and
Skill Development

• The therapist uses a variety of teaching methods
  including role playing, coaching, direct
  teaching, work sheets, audio/visual materials and
  homework to help family members learn and use new
  skills.

20
Homebuilders Intervention Activity Provision of
Concrete Services

• The therapist advocates for and provides concrete
  good and services including transportation, food,
  clothing and accessing funds to pay for rent,
  utilities etc, which are directly related to
  achieving the familys goals.

21
Homebuilders Intervention Activity Collaboration
and Advocacy

• The therapist collaborates and advocates with
  formal and informal community resources and
  systems while teaching family members to advocate
  and access services and supports for themselves.

22
Homebuilders Intervention Activity Transition
and Service Closure

• Prior to the conclusion of services, the
  therapist and family assess goal attainment, plan
  for the maintenance of progress, and collaborate
  with the referring worker and other organizations
  and resources to address ongoing service needs.

23
Development and Expansion of the Homebuilders
Model

• 1974 Program began in Washington state
• 1978 1994 Homebuilders expanded
  statewide in Washington
• 1987 1990 Homebuilders project in
• New York City

24
Dissemination of the Homebuilders Model

• National Dissemination begins 1988
• New Jersey First state to attempt replication
• Disseminated in 40 states including Alabama,
  Indiana, Kentucky, Louisiana, Michigan, Missouri,
  New York, Pennsylvania and Washington

25
International Dissemination of the Homebuilders
Model

• International Dissemination Since 1990
• Australia, Belgium (Flanders), Bermuda, Canada,
  Finland, Germany, The Netherlands, Portugal and
  the United Kingdom.

26
Changes/Enhancements to the Intervention Model

• Focus on Critical Thinking and a Reflective
  Practice Framework
• Use of Motivational Interviewing Strategies
• Incorporation of the NCFAS/NCFAS-R into the
  assessment, goal setting and service/treatment
  planning process
• Greater focus on Functional Analysis of Behavior

27
Reflective Practice Model
Personal Framework
Planning
Implementation
Assessment
Evaluation/Outcome
28
North Carolina Family Assessment Scale
(NCFAS/NCFAS-R)

• NCFAS Assessment of family functioning on 5
  domains of interest
• Environment
• Parental Capabilities
• Family Interactions
• Family Safety
• Child Well-Being
• NCFAS-R includes all of NCFAS plus two
  additional domains unique to reunification
• Ambivalence
• Readiness for Reunification

29
NCFAS Rating Scale
Clear Strength Mild Strength Baseline/ Adequate Mild Problem Moderate Problem Serious Problem
2 1 0 -1 -2 -3
30
Changes/Enhancements to the Program Development
Process

• Comprehensive Training for Therapists and
  Supervisors
• Site Development Process Program Start-up and
  Ongoing Consultation Process
• Homebuilders Standards and Fidelity Measures

31
Homebuilders Training 1970s-1980s

• Initial Homebuilders Training (3-4 Days)
• Special Topics (Anger Management, Depression,
  Assertiveness Skills) (3-4 Days)

32
Homebuilders Training 2008

• Homebuilders Core Curriculum (4-5 Days)
• Working with Drug Affected Clients Motivational
  Interviewing and Relapse Prevention (3 days)
• Assessment and Outcome-based Goal Setting (2
  Days)
• Implementing Cognitive and Behavioral
  Interventions (2 Days)

33
Homebuilders Training 2008

• Improving Decision Making through Critical
  Thinking (2 Days)
• Domestic Violence Strategies for In-Home
  Practitioners (2 Days)
• Working with Parents with Cognitive Limitations
  (1 Day)
• Issues in Reunification (1 Day)
• Ethical Issues for In-Home Practitioners (1 Day)

34
Homebuilders Training for Supervisors 2008

• Core Curriculum for Homebuilders Supervisors (3-4
  Days)
• Program Consultation and Quality Assurance Skills
  for Homebuilders Supervisors (2-3 Days)

35
Program Development and Implementation Strategies

• Program replication in Washington State and New
  York CityHomebuilders staff relocate to start
  new programs
• Program development across the United
  StatesDevelopment of site development
  strategies and process

36
Site Development Strategies

• Program start up TA and consultation
• Initial and ongoing training
• Weekly telephone consultation
• Client record reviews
• Quarterly on-site consultation visits including
  observations of home visits and team consultation

37
Fidelity Measures Immediate Availability and
Response to Referrals

• Indicator Provider agency does not maintain a
  waiting list.
• Performance Measure When provider agency has
  an announced opening, eligible referrals are
  assigned to a therapist on the day of referral.
• Indicator Therapists meet with families within
  24 hours of referral.
• Performance Measure 75 of families receive
  their first face-to-face visit within 24 hours of
  referral 85 of families receive their first
  face-to-face visit no later than the end of the
  day after the referral. If intake is NOT achieved
  within 24 hours, 95 of those records document
  the reason for not achieving this standard as
  being due to the familys

38
Fidelity Measures Promoting Safety

• Indicator Family safety is increased during the
  intervention
• Performance Measures
• When there is a threat of self-harm, child
  abuse or neglect, or physical violence between
  family members, 100 of interventions include a
  safety plan and, if applicable, a service goal to
  address the threat in all cases when serious
  safety concerns exist, therapists maintain
  frequent contact with family members (at least
  daily more if indicated) therapists
  strategically schedule sessions at times when
  there is increased potential for problem behavior
  to occur therapists respond to crisis situations
  on a 24/7 basis.

39
Fidelity Measures Promoting Safety

• Indicator Family safety is increased during the
  intervention
• Performance Measures When the NCFAS family
  safety domain is rated below baseline at intake,
  at least 80 of interventions show an increased
  rating in this domain at service closure on the
  Homebuilders Referent Feedback Survey, therapists
  receive an average rating of 4.0 or higher on the
  question How satisfied were you that the
  therapist adequately addressed safety issues?

40
Fidelity Measures Comprehensive Assessment

• Indicator The therapist completes a
  comprehensive written assessment.
• Performance Measures Therapist completes a
  functional analysis of behavior therapist
  completes the NCFAS/NCFAS-R therapist gathers
  information in a variety of ways from various
  sources family assessments include information
  about family strengths, values, skills, problems,
  needs and barriers to goal attainment.

41
Fidelity Measures Cognitive and Behavioral
Approach

• Indicator The therapist applies cognitive and
  behavioral principles and evidence-based
  strategies to facilitate behavior change.
• Performance Measures Therapist uses
  behaviorally specific, value neutral language to
  describe problems and strengths. Therapist helps
  family members understand how behaviors are
  affected by antecedents, consequences, past
  learning, life experiences, culture, and other
  factors. Therapist uses evidence-based behavioral
  strategies with families to increase and/or
  decrease behavior. Therapist helps families learn
  how to utilize behavioral strategies to increase,
  decrease or teach new behaviors to their
  children. Therapist use evidence-based cognitive
  strategies with families to effect change.

42
Program Evaluationand Outcome Measures

• North Carolina Family Assessment Scale
  (NCFAS/NCFAS-R)
• Behavior Change Measures
• Placement Prevention/Reunification Rates
• CPS/CAN Re-referrals
• Consumer/Family Satisfaction
• Referring Worker Satisfaction

43
Results of Meta Analysis of Homebuilders Model

• Review and analysis of all rigorous evaluations
  of Intensive Family Preservation Services (IFPS)
  programs. WSIPP sorted these evaluations based on
  fidelity to the Homebuilders model.
• Findings
• IFPS programs that adhered closely to the
  Homebuilders model significantly reduced
  out-of-home placements and subsequent abuse and
  neglect. Estimated that such programs produce
  2.54 of benefits for each dollar of cost.
• Non-Homebuilders programs produced no
  significant effect on either outcome.
• Summary from Intensive Family Preservation
  Programs Program Fidelity Influences
  Effectiveness, February, 2006. www.wsipp.wa.gov

44
Evaluations Demonstrating Fidelity to
Homebuilders Model

• Blythe, B. S. Jayaratne. (2002, March 22).
  Michigan Families First effectiveness study.
• lthttp//www.michigan.gov/printerFriendly/0,16
  87,7-124--21887--,00.htmlgt, accessed 02/07/06.
• Feldman, L.H. (1991, December). Assessing the
  effectiveness of family preservation services in
  New Jersey within an ecological context. Trenton,
  NJ Bureau of Research, Evaluation and Quality
  Assurance, Division of Youth and Family Services,
  Department of Human Services.
• Fraser, M.W., E. Walton, R.E. Lewis, P.J. Pecora,
  W.K. Walton (1996). An experiment in family
  reunification Correlates of outcomes at one-year
  follow-up. Children and Youth Services Review
  18(4/5) 335-361. Note This program is also
  evaluated by E. Walton (1998).
• Mitchell, C., P. Tovar, J. Knitzer (1989). The
  Bronx Homebuilders Program An evaluation of the
  first 45 families. New York Bank Street College
  of Education.
• Walton, E. (1998). In-home family-focused
  reunification A six-year follow-up of a
  successful experiment. Social Work Research
  22(4) 205-214. Note This program is also
  evaluated by M.W. Fraser et al. (1996).

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Rigorous Experimental Study

• Blythe Jayaratne (2002)
• High-risk families (court had approved child
  removal), true random assignment IFPS or
  traditional services (including foster care)
• At 6 months
• 94 of IFPS children at home/relative
• 34 of non-IFPS children at home or
• with relative
• At 12 months
• 93 of IFPS children at home/relative
• 43 of non-IFPS children at home or with relative

46
Research Random Assignment Studies
Blythe, B. Jayaratne, S. (2002). Michigan
Families First Effectiveness Study. Retrieved
April 24, 2006 from http//www.michigan.gov/dhs/0,
1607,7-124-5458_7695_8366-21887--,00.html 81
of treatment group avoided placement. 51 to
61 of comparison group avoided placement.
Fraser, M., Walton, E., Lewis, R., Pecora, P.,
Walton, W. (1996). An experiment in family
reunification services Correlates of outcomes at
one year follow up. Children and Youth Services
Review, 18 (4/5) 335-361. 92 of the
treatment group returned home. 28 of the
control group returned home. Feldman, L.H.
(1991, December). Assessing the effectiveness of
family preservation services in New Jersey within
an ecological context. Trenton, NJ Bureau of
Research, Evaluation and Quality Assurance,
Division of Youth and Family Services, Department
of Human Services. 57 of the treatment group
avoided placement. 43 of the control group
avoided placement.
47
Research Comparison Group Studies

• Fraser, M. W., Pecora, P.J., Haapala, D.A.
  (Eds.). (1991). Families in Crisis The Impact of
  Intensive Family Preservation Services. New York
  Aldine de Gruyter.
• 71 of WA treatment group and 62 of UT
  treatment group avoided placement.
• 15 of comparison group avoided placement.
• Mitchell, C., Tovar, P., Knitzer, J. (1989).
  The Bronx Homebuilders program An evaluation of
  the first 45 families. New York Bank Street
  College of Education.
• 74 of the treatment group avoided placement
• 65 of the control group avoided placement.
• Wood, S., Barton, K., Schroeder, C. (1988).
  In-home treatment of abusive families Cost and
  placement at one year. Psychotherapy 24(3),
  409-414.
• 74 of the treatment group avoided placement.
• 45 of the control group avoided placement.

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Research Statistical Control Group

• Kirk, R.S. Griffith, D.P. (2004). Intensive
  family preservation services Demonstrating
  placement prevention using event history
  analysis. Social Work Research 28(1), 5-15.
• 81 of treatment group avoided placement.
• 51 to 61 of comparison group avoided
  placement.

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What We Have Learned

• Implementation of the Homebuilders Model isnt
  easy and program development takes time and
  resources
• Public and private agency support are critical to
  successful program implementation
• Payment systems can support or hinder successful
  implementation
• Ongoing training, consultation and quality
  enhancement are essential to long term success

50
What We Have Learned

• Staff selection is critical there must be a
  job fit
• Supervisors are a key to successful
  implementation
• A focus on maintenance of changes is critical
  no program can be successful without other
  community supports and resources
• Successful programs can easily be dismantled or
  diluted
• Ongoing research is needed and difficult to
  accomplish

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Keys to Successful Program Development and
Implementation

• Obtain wide-spread support
• Ensure adequate funding and effective payment
  systems
• Choose provider agencies with congruent values,
  policies and capabilities to provide needed
  support to program staff
• Develop effective referral pathways and processes
  to ensure that adequate and appropriate referrals
  are made
• Provide on-going training and consultation to
  public and private agency staff
• Collect and review program implementation and
  outcome data and focus on quality enhancement

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Other Changes Over the Past 30 Years

• Technology cell phones, internet, web-based
  client paperwork system phones, client computers,
  email, text messaging etc
• Gas Prices more costly to provide in-home
  services
• Interest, acceptance and encouragement of program
  models
• Greater interest in research and evaluation
• Work force changes

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To learn more.

• Visit our website at www.institutefamily.org
• Call us at 253-874-3630
• Email usShelley Leavitt sleavitt_at_institutefami
  ly.org