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CANS in Practice Transcript

CANS in Practice Objectives Voiceover transcript: So far, we have examined the characteristics and structure of the CANS tool. We have also reviewed CBHI’s values and array of services. In this next section, we will explore how the CANS can be integrated into daily practice to further these values, and assist families to get the most benefit from the services available. Please review the objectives for this section.

CANS and CBHI Voiceover transcript: CANS was selected as a comprehensive summary assessment tool because CANS shares CBHI’s values. CANS is child/family centered, strengths based, and culturally responsive. It fosters collaboration and integration, and assists workers and families to continuously improve. In the next video, Jack Simons responds to Dalene Basden’s question about family engagement and provides an overview of clinical practices that are prompted by CANS.

Video: How Does CANS Help Clinicians Be Child/Family Centered? Video transcript: >> So, Jack, can you tell me how does the CANS help to engage families in all aspects of the treatment process? >> Well, I think it does help. But, you know, if a clinician isn't oriented towards engaging families and listening to them, the CANS isn't going to make a big difference. So I think the first thing is you really need to understand how important it is to understand the family's culture, their aspirations, their goals, and to understand all the things that they can do to make things happen for the kid, all the things that they've already tried to do. So first a clinician has to come from that place of understanding why family engagement is so important and what it looks like. But then I think the CANS provides some useful structure. So among other things, it requires you to have a conversation at least every 90 days with a family about are we still moving towards these goals and are these still the goals that are most important to you? So I think that's some useful structure. It also serves as a prompt for a clinician to ask questions that, you know, we all should ask but sometimes we need a reminder. So I think some of the questions in the cultural consideration section, for example, get clinicians thinking about things that they sometimes might fail to ask about the way the family thinks about the problem and the way the family thinks about the treatment system. Similarly, I think child strengths -- that's a great question. People may get tired of being asked the same question over and over, but that's really a sign that you're not really asking. I mean, because the question is, "Has something changed? Is there something new that we didn't see here before that we need to know about now?" So I think the 90-day prompt and the variety, the range of CANS questions can just sort of help clinicians to keep thinking about this issue, about there's always something new, but what is it with this situation?

CBHI and CANS Values: Child/Family Centered Voiceover transcript: The practices that Jack Simons highlights are: understanding the importance of family engagement and the family’s point of view, asking questions to discover strengths, exploring family culture, and conducting frequent and ongoing reviews of progress.

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Engaging Families in CANS Voiceover transcript: CANS is child and family centered in many ways. In the next video clip, Medgyne Lubin and Maria Torres discuss a few ways that CANS helps keep the conversation focused on the child and family.

Video: Engaging Families Through CANS from a Clinician's View Video transcript: >> Tell me, Maria, how is CANS related to child-centered and family-driven work that you do? >> Sure. So I think what the CANS instrument does really well is it gives clinicians the tools to ask very guided but loosely framed questions that put the family and the youth at the center of the experience and the dialogue. So and it does that by using common language. And by that I mean it's not too jargony, it's not too technical, it's not all acronyms. It's really tell me what's happening, tell me about your experience with services, and really putting the family at the center and making them the expert of their experience. And then the clinician learns from them. I can talk about the CANS and how it may be used, but I'd love to hear your experience of using the CANS instrument and how it helped you kind of get to putting the family at the center of treatment. >> So working on the CBAT, if a family comes in with CBHI providers already in place, we get to read their CANS. So it's helpful to know what -- the work that's being done in the home, how it's helped the family accomplish their goals, where they're at with meeting their goals, what the family strengths are, what's helpful, what's not helpful for them, and what the needs are. Because when they come to the CBAT, they're in an acute state. They're here from 10 to 14 days. So we have literally two weeks to stabilize, maintain safety, and then discharge back to the home settings. >> You know, and here you talk about it really kind of brings home two things that I think are really important. One is that, you know, I feel like the CANS is giving you a head start in getting to know new families that you haven't met before and having that kind of common document travel with the family. So you receive it, and then it gets passed off when the child leaves, which is really nice. Having that opportunity to build off of and not start from scratch is really a nice thing about the CANS.

Family Engagement Through CANS from a Parent’s View Voiceover transcript: In this next video, Dalene gives us one parent’s view about how the CANS can be used to enhance engagement.

Video: CANS Is Not About a Score, It's About a Conversation Video transcript: >> So tell me what you think is the best process for engaging families in the conversation that leads to the scoring of the CANS. >> Well, I think that key is what you just said, engaging families, conversation. It's all about conversation. When they're scoring the CANS, the problem with using that language, scoring, this is not about a score. Although for purpose of the CANS I understand that you have to have a score in order to get the bottom line from the clinician's point of view, what they need to do. But for families it's all about conversation. And to have an open and honest shared conversation is the best way to get to where you need to be with families and to engage families.

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>> And then how do you share the -- how would you from your perspective suggest sharing the completed CANS with families? >> I would suggest as far as sharing the completed CANS and the information, the data is with honesty -- not brutal honesty but with complete honesty to let the families know. I mean, you're having a conversation as you go along, so you're sharing information back and forth, and that's good. And it helps families and that's engaging families. But when all is said and done, to be honest about the results where the family stands, to really highlight the strengths that have been discovered. And for those areas where they may need support in what we discovered the needs to be, to be concrete with the support that you're going to be able to provide, to know that the resources that you're going to suggest are available resources to families and they're not just something fly by night or made up and not to whitewash any of the areas that need improvement as well. To be able to say to a family, "You know, this is wonderful, this is what we've done. This is what we've discovered. And this is what we see is your needs. And based on the conversation that we've had, do you agree this is your needs and how can we move forward with this?" >> So you definitely ask for agreement as part of the process as well? >> Absolutely. I think that families need to be on board from the beginning agreeing along as we go along the way that the information that we're revealing as we go along is relevant, is correct and true, and is going to in the long run be able to help the family and particularly the child -- identified child -- to be successful.

Practices to Include in the Conversation Voiceover transcript: As Dalene notes, conversation is key. Families want to know what the CANS is and why it matters. Other important practices to incorporate into that conversation include: Describing what you have observed honestly, but without being judgmental; focusing on child and family strengths; providing concrete, useful resources to help with their identified needs; asking for the family’s input and agreement throughout the process; and celebrating successes.

CBHI and CANS Values: Strengths Based Voiceover transcript: As we have already heard, CANS encourages us to pay attention to strengths. We asked Anthony Irsfeld and Beth Chin to discuss how they use CANS in their strengths-based care. Listen to what they have to say:

Video: CANS is a Cross-Program Tool for Attending to Strengths Video transcript: >> CANS provides a sort of cross service, universal tool by which we can, you know, all pay attention to this aspect of the families we're working with. You know, for a long time, we've had, you know, the DSM, which is our cross program, universal tool for diagnosing people, and you know, categorizing their problems. And we have an opportunity here to all be using, you know, the same tool, that really asks us to yes, categorize needs; but also, yes, pay attention to some of these strengths. And I think you're right, I think that, you know, we can be talk about strength based with families as part of our direct work with them but as a system, if we're going to value or honor that value of being strength based, then you

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couldn't be more correct. And that we have to have a way of getting on the same page about where these strengths exist with each other. >> It's exciting to think about now that we can -- you know, sharing CANS, we can view each other's CANS. If a clinician is writing these great things in the strength section and it might be something - some new information to the care coordinator, or vice versa, and how that can open up a conversation and really guide the conversation in the direction of making some goals on the next care plan.

An Opportunity to Focus on Strengths Voiceover transcript: Next Beth discusses how the CANS prompted a therapy team she worked with to take advantage of an important opportunity.

Video: A Strengths Example from Beth Chin >> One of the things that I was thinking about is this youth that we're working with that he had this great interest in gardening and nobody ever knew that. And it just happened to come up in a conversation with the clinician and she had made a note about it on the CANS. There was something in terms of - it was under talents and interests that he had an interest in gardening, and this was new information. And it really was a great springboard to talk about, okay, how can we pull this into the next care plan? How can we engage the youth and the family in talking about this when we're planning the next care plan meeting, and seeing if this - we could use this as part of our brainstorming session? And if the clinician hadn't put that on her CANS, then it would have been a missed opportunity.

Introduction to Nick’s Strengths Voiceover transcript: Now, let’s talk with Nick. Imagine completing the strengths domain of CANS for Nick as you listen and watch.

VIDEO: Nick’s Strengths Video transcript: >> I love reading, probably done like half -- like half of this shelf already. I just love these. I just love books. They’re just awesome.one of my favorite - my favorite one is this one, it's very funny. It's called Nerds. It's very funny. I like to read Captain Underpants, Diary of a Wimpy Kid. I can't find the book it's 101 ways to like creep your enemies, and parents, or something, out. It's like 101 Ways to Creep Your Parents and Enemies Out, I'm pretty sure. Oh, Just for Boys, this book, it's pretty cool. It's - it like - it's like tells everything just for boys. I'm very good at math, like adding fractions and subtracting fractions, I'm so good at now. I'm multiplying fractions, dividing fractions, equivalent fractions, I'm so good at those, and I’ve very good at math so I just - it's one of my favorite subjects because I'm so good at it. And other things, I'm not so good at. My room is so clean because like, I'm a very neat person, I like clean stuff. Like, if something's on the floor, immediately I'll just pick it up. In third grade, I used to play recorder but I'm going to - I'm going - I'm pretty sure I want to do an instrument next year. I want to play the flute. I want to be a cop because they get to arrest people and they have guns and they [inaudible], you can handcuff people, and you get to drive this cool car that has a - in the future, I think we'll have a computer as the stereo in it, I hope, and they go Dunkin Donuts and eat some donuts and coffee. I'm a gamer. I love gaming. I'm not so creative, I've never had that imagination, not that much. But when it comes to Legos, I do. And when it comes to Minecraft to build stuff, I do. I like to dance too, and it helps me like express myself, like my dancing, and my - like, singing or some - whatever I do. My teacher and

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my - lunch aide are like the nicest people in the whole school, besides me.

CBHI and CANS Values: Culturally Responsive Voiceover transcript: CANS also prompts us to be responsive to the youth and family’s culture. The CANS items in the Cultural Considerations domain encourage a dialogue with the youth and family about their culture and values, which can then be used to inform the care or treatment plan. You might recall that earlier in the training Maria Torres briefly described how CANS not only affords the opportunity for clinicians not only to think about the culture of their clients, but also to examine their own identities in relation to their clients. We’ve included the same video again in case you want to review it here.

Video: Self-Analysis of One’s Culture Video transcript: >> I think what the CANS does very well is it raises the issue of cultural competence, you know, thinking about culture and what's important to the families that you see. So, really trying to help the clinician think about what is the family's experience, what's important to them, where have they been and how are they received in those systems of care, wherever they were, thinking about how they are interpreting what's happening in their lives. So, the CANS really helps through that way of asking questions and really also asking the clinician to reflect about their own culture. How do I kind of contribute or how do I - my understanding of what's happening, how do I reflect that and think about that as I work with this family in a meaningful way.

Introduction to What CANS Means by Culture Voiceover transcript: We have also seen that there are many different ways of understanding the word “culture.” Our interviews in the field raised some good questions about what is meant by culture and how CANS helps one be culturally responsive. In the next video, Maria fields a question from Celia Hilson, who asks what CANS means by culture.

Video: Celia O. Hilson and Maria Torres Discuss What CANS Means by Culture Video transcript: >> In the CANS on the - in the second about culture, it uses the word culture a lot. And so, I'm often curious when I read it is, is cultural a broad term and is there a way to specifically define it? How can it fit these more specific experiences around race, identity, sexual orientation, gender? So, is it about all of those things? >> But it's trying to be as inclusive as possible to all the different communities that can be out there in the world, right? So, thinking about immigrant populations, what does it mean to be Latina and black, what does it mean to be someone with a vision impairment, or a hearing impairment when you're interacting with the system, so deaf community culture. What does it mean to be a devout orthodox person navigating a system that may not respect your religion, you know? So, I think it's trying to be really encompassing and that might feel difficult because it's not naming something so directly.

Cultural Considerations Goals Voiceover transcript: We found the issue that Maria and Celia discuss to be one of the more difficult questions about being culturally responsive: how does one go from a broad understanding of racial, ethnic, and gender identity

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issues to the culture specific of the youth in his or her family? CANS helps: the cultural considerations domain of CANS helps us approach culture as a regular part of our engagement and assessment processes. The cultural considerations domain also reminds us to ask for important details about the youth and family’s needs and about their access to appropriate support. Does the child or family require a language interpreter? Does the family or their community have particular experiences that lead them to be cautious about engaging in treatment? Does the clinician need to be aware of socioeconomic barriers to care, such as insurance, co-payments, or the cost of transportation? Research also tells us that the daily experience of discrimination can increase stress. The CANS items remind us to consider these experiences, to ask families about them, and to actively engage in mitigating them when they occur in the helping system. As Dalene told us, yes, these questions may seem strange at first, but they get everyone talking about cultural issues that matter. Outpatient therapist Joel Colburn addresses these issues with the questions he asks when people come to his office:

Video: An Example of Interacting with Clients About Culture Video transcript: >> It's important to know - for me, right - that I do have - I always have power as a clinician, that that's - there's always a power differential. And the office is not neutral, you know? I'm part of an agency, I'm part of an institution, I'm part of systems. So, that's something that I'm thinking about that - to the extent that I can, I like to name that. Like - and I think one question that I ask is, what was it like for you to come in today. I ask that kind of as we're going through treatment to sort of talk more about the relationship and the work. But certainly from the beginning, what's - what - what's it like for you to come in here. You know, what were you thinking before you came in? Were you imagining something? You know how does this match up to that and why or why not. You know, what has therapy looked like in the past? You know, what have your relationships to therapy and therapists and systems look like in the past? You know, how is this similar or not? And is it what you want? You know, so I'm thinking about those things. And I think also really honoring that it takes a lot of - like just a lot of courage and I think - I don't know, like a real commitment to someone and their family to come in to someone's office and say, I want to work with you. Like, I want help, you know? I want to let someone else into this. And so I try to really acknowledge and respect that.

Further Examples of Discussing Culture Voiceover transcript: And in the next video, Sara Belding talks about the ways she sees culture, and how she engages with the family and other providers around issues of the family interacting with the systems that affect it.

Video: Some Therapist Roles in Being Culturally Responsive Video transcript: >> Kids that are struggling look similar, regardless of where they're coming from, or what their background is, just because they're human beings, and we respond to things as human beings in particular ways. I think that some of the things that the families themselves might be experiencing, depending on what their makeup is, that they could be experiencing some oppression within systems, whether that be, you know, a homophobic DCF worker, or, you know, a school that really has a difficult time kind of wrapping their mind around a same-sex, same-sex parents. In particular settings, IHT workers go in and, like, for instance, going to an IEP meeting at a school, and they can really help, they can be a neutral party. I mean, they're there with the family, and in a lot of ways, for the family, but they can help translate some things for the school, or help the school take the family's perspective a little bit more. And, in some ways, it feels like you're doing family therapy within the system itself, with the

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school as a piece of that family system, and then the family, and the youth. So, it's kind of negotiating that process, and how best for the family to feel heard in systems where maybe they feel silenced, but also how to help the family also hear what the systems have to say, and incorporate that, as well. It's helping to translate what the family's experience is, and maybe what language they use to talk about things, or their understanding of an issue or a problem. And so, because I think sometimes, other providers, or other systems make assumptions about what's happening, and there's a lot of blame. When a kid is having trouble at school, there's a lot of blame about what's going on at home, what are the caregivers doing wrong that's resulting in this behavior? And so, kind of trying to take away some of that shame and that blame away from that interaction, and really normalize maybe what's going on at home, or have them understand a little bit better the circumstances that the family is living in, and, you know, that they're living in poverty, that, you know, the parents are really stressed. They don't know how to put the next meal on the table, and that these are really real things that are impacting the family system, and their ability to parent, and to parent effectively sometimes. And, unfortunately, the kids are impacted by that, as well.

The Cultural Considerations Domain Gets the Conversation Started Voiceover transcript: We hope that using the Cultural Considerations domains in the CANS will help provide a strong cultural sensitivity for your understanding and work with youth and families. Maria Torres worked with the team that developed the Cultural Considerations items. Here she discusses her hopes for how the items might be used.

Video: Maria Torres’ Hopes for How CANS is Culturally Useful Video transcript: >> So Maria, I know you and I were both involved in editing the cultural considerations domain; can you tell me a little bit about why you got involved in that and why you think it's important? >> Thinking about culture and its implications on families is critical to really assessing how services can be used and how they can be helpful. So it was a real wonderful opportunity to contribute to helping clinicians have better tools to get to the heart of working with families better. >> And what's your hope about how that domain's going to be used? If you're out in the field watching clinicians use it, what do you hope to see? >> I would hope that they use it. I think the questions are -- when you go through the instrument itself, you know, the introduction really sets up a framework for thinking about privilege, for thinking about cultural concepts -- what is culture, how is this family viewing themselves in the world, how do they view the system, how have they been received in the past? So I think, you know, there's a nice intro there. There's some questions that prompt clinicians to think maybe not necessarily using those same exact questions, but using your experience, what you know of this family, what you've gotten from them. How can this help nudge you to feel more comfortable to ask questions about culture?

Culture and Clinical Practice Voiceover transcript: For additional resources on culturally responsive practice, check out the American Psychological Association’s interview guide, called the Cultural Formulation Interview, for how to ask questions about these important issues.

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CBHI and CANS Values: Collaborative and Integrated Voiceover transcript: CANS also facilitates the collaboration and integration that is needed when families are working with multiple providers and different state agencies. CANS helps establish a common language and a standard set of strengths and needs to consider. The ratings on the items are easily understood, provide touchstones for further discussion, and can be shared among everyone involved to help in intervention planning, and tracking of progress.

Supervisors and Clinicians Also Use CANS to Help Collaborate Voiceover transcript: And as Erin Lechter and Patti Cedrone discuss, CANS helps supervisors and clinicians collaborate around families, particularly if the supervisor ensures that clinicians are comfortable using CANS.

Video: Supervisors and Clinicians Use CANS to Collaborate Around Families Video transcript: >> As a clinical supervisor, can you talk about your role with the clinical staff that you are working directly with who are administering the CANS assessment? >> Sure. I think with new clinicians, you always want to make sure that they really understand what the tool is and how to use it, so really going through, making sure they're trained, answering questions, maybe even practicing. If they're - if you know they're going to be working with a family soon, sort of sitting down, making sure they understand the language, that they can help the family understand the language. And then once the assessment's been done and they've got the score sitting in front of them, helping them to see how it is going to drive their treatment, how they're going to write their treatment plan based off of it. and then depending on what areas are highlighted, what practices are they going to use in order to address each of those items, or each of their goals and their needs. >> Do you find that clinical staff are nervous when they're completing their first CANS assessment? >> I think sometimes they are. I think that anytime you sit down with a family, especially a family at a point of need, that you really want to get it right and I think making sure that they feel comfortable and confident. But I think one of the greatest things about the CANS is that it's pretty easy to use and once you've got the hang of it, it's a really easy tool to use with families and to help them kind of understand it and get through it. >> I think what I've told clinicians that I've been supervising is that the first few that you do, yes, you kind of have the document in front of you and it's very cumbersome. There's lots of questions but as you feel more comfortable administering the CANS, you can kind of put that aside and just have a conversation and the questions kind of just roll off your tongue and you can really just sit down with a family, with providers, with the child, whoever you're going to be interviewing, and just really have a conversation where you ask a lot of questions that sometimes we don't typically ask in a routine assessment. But as you get more comfortable doing them, then it's - you know, you can kind of put the document to the side and it's really just engaging with the family.

Differences in CANS Ratings Can Help Communication Voiceover transcript:

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In the next clip, Risa Sugarman and Bethany D’Amico use the issue of differences among providers in ratings of CANS items as an example of how CANS can facilitate communication and collaboration among providers.

Video: Example of How to Use Differences in CANS Ratings Video transcript: >> So as an in-home therapist I've had the situation where I have disagreed with an ICC on a rating. How would the CANS help sort that out? >> The CANS would really help just in terms of facilitating communication. So in looking at not just the exact item that there might be disagreement with, but each person has his or her own CANS on the same child. And looking at the entire assessment together and having discussions about the ratings. And then getting to that particular item that you are in disagreement about and really talking with each other why, for instance, you rated something a two and she rated it a one -- there is a difference between a two and a one. A two you're taking action, a one you're keeping an eye out. And that can result in different thoughts in terms of the treatment plan. So I think it really just opens up the communication and that there can be disagreements with different levels of providers involved with the same family. And that should be expected. I think the way to really deal with it well is to really look at -- have the CANS in front of them and have an important conversation about all of the ratings and looking at where there is any disagreement. And more information could be learned from one provider to another, which may end up changing one of their ratings. So it's really -- I think the focus is really on communication.

Collaboration and Discrepancies in Ratings Voiceover transcript: A little more discussion about differences of opinion in rating CANS might be helpful. Discrepancies in ratings can occur for several reasons. For example, differing levels of engagement with the youth or family may affect the responses family’s give or what they choose to share. Ratings might also reflect fluctuations in functioning at different points in time, or in different settings. Differing cultural biases among providers or family members can contribute to differences in ratings as well. However, as Risa stated, these differences can provide a basis for meaningful discussion about what has been observed and conclusions that have been drawn about the family and treatment. These discrepancies should be seen as opportunities to compare information on the same topics, using the uniform language of CANS to help reconcile differences. In the next video, Tom Butero and Tressa Rogers discuss a few other ways that differences in scoring the CANS lead to opportunities to gain meaningful insights about the youth and family.

Video: The Consent Process Fosters Collaboration Video transcript: >> When we talk about a family having three or four providers and we talk about the CANS being a working tool, as the hub provider I know that I complete CANS; should other providers being weighing in on the CANS? Should they be completing their own version as well? Or how do we do that as a collaborative effort? >> Different providers are required to do them whether you've done one or not. Even if you're the hub, let's say you're the hub with the ICC program and the family has an outpatient clinician. The outpatient clinician, even though they're not the hub, is still required to do the CANS. But again, it's the same

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process, that the outpatient clinician would have access to your CANS or someone else's that was done previously via the virtual gateway. So in that sense you're able to look at each other's scores, you're able to compare how you rated the child and the family versus how the outpatient clinician did the same ratings. And, again, with releases of information from the family, talk to each other, "Well, I thought I scored this area like this, you scored it that way. What are you seeing that I'm not or what am I seeing that you're not seeing? And let's talk and let's compare notes a little bit." It's not necessarily that you want to come to an agreement on the scoring, but it does allow you to have input into each other's basic rationale as to why you scored something a certain way and someone else may have done it a little bit differently. >> So it sounds like it's made to make everything more comprehensive. So if I'm someone who's home-based, an outpatient is office-based; we may score differently because we might see different strengths and different needs within the family dynamic. And maybe having two different variations tells us what we need to focus on in treatment. >> Exactly. And also, not only that, but the difference in in-home versus office-based outpatient is a good example because the context in which the CANS is being done is different. You're going to get -- presumably you're going to get somewhat different scores from a family if they're in their home environment, feeling a little more comfortable being in their home and providing information, as opposed to coming into an office, which is a more formal setting, and sitting down with a clinician and working on the CANS. And that can have an effect on scores, absolutely. >> And opposed to how a child reacts to someone, how they present when they're by themselves, that's compared to within the family dynamic. You may have someone that struggles within the family dynamic that appears to be more stable in the office setting or someone who, you know, feels more comfortable when they have support when they're not alone, who struggles in the office setting. it may seem more isolative or less social. >> And also, we can't dismiss the impact that individual providers have. Everything from the gender of the clinician, age, how they dress, how they relate -- all these things will have an impact on the family not just in terms of the CANS but in general how they're relating to that person. But you got to take all those things into account as well.

CBHI and CANS Values: Continuously Improving Voiceover transcript: A final point we want to make about CANS and CBHI’s values is that CANS data supports continuous improvement. We can use CANS data to improve our clinical practices for individual youth and families. CANS data supports broader improvements for a provider agency as well, such as identifying areas of clinical excellence or monitoring training needs. CANS can also help inform the entire CBHI system about strengths and needs—including resource gaps, trends in diagnoses, and demographic information. As a method for summarizing data, CANS is an essential component of a continuously improving system of care. We will discuss the uses of CANS data in a few slides. But first, some exercises to check your understanding of what we have presented so far.

Interactive Exercise 1

Interactive Exercise 2

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Interactive Exercise 3

Information Organized with CANS Voiceover transcript: The first step to discovering strengths and needs is to gather information. CANS is the tool we use for summarizing, organizing, and communicating this information with the family and across all providers who have been given permission to see the CANS by the caregiver or young adult. CANS is a big part of the Case Conceptualization model we discussed earlier and shown here. In the next video, Sara Belding and Amanda Starfield talk about a family where making sense of a cluster of 2s and 3s helps Amanda better understand the work, and helps her engage with the family about her ideas.

Video: A Use of CANS Ratings of 2s and 3s in Case Conceptualization Video transcript: >> The new case that you just opened, I know that you this last week sat with a family and did the CANS with them. So I was curious, where when were you collaborating with them on the CANS did you rate twos and threes? >> Definitely family communication has been really hard, experience of trauma. There's a lot of depression and anxiety. Hypervigilance that comes out as there's a previous diagnosis and sort of a current understanding from the family and from the school around ADHD. And I wonder about that in the context of all the things that have happened for this parent and this kid. >> What meaning does the family make of the problems that they're identifying? What do they think is causing those problems? >> It's interesting. I've been wondering a little bit about it. But what they told me was that at this point there's so much conflict and there's so much fighting going on at home and a lot of refusal to just participate in the home. So this kid is really not taking care of daily hygiene, not able to participate in chores, getting to school some days out of the week but not others, and having a lot of difficulty sleeping at night and not wanting to sleep some nights. So there is an experience the parent is really frustrated. They're really overwhelmed. My understanding was this parent was incredibly overwhelmed, which was another place that I put family stress for the parent really high. I put that really at a three. And so this parent in the moment, what they said to me was that this kid just doesn't care. And really, when we looked at sort of where the conduct and the oppositional stuff was, was rating those at probably higher than I would. And so we talked a little bit about that, but I think we need to talk more about it and what this really fight response is in that moment. Because I was really wondering about and thinking about this hypothesis of this trauma frame and where that trauma frame might fit in for this family. And I really -- the parent was really engaged, I mean, really present. Nervous -- appeared to be nervous. Was really apologizing a lot about the state of the house, which to me looked really fine. And so we talked a little bit about that experience of me coming into the home. I wonder in a moment where she was feeling a little less overwhelmed if she might have other understandings also of what's going on right now, too.

Data Do Not Add Up to a Treatment or Care Plan Voiceover transcript: Although CANS provides summary data, we all know that data do not add up to a treatment or care plan.

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Next, Erin Lechter shares with Patti Cedrone how therapists are able to examine the data from CANS in the context of other information, the clinician’s training and experience, and the family’s input to create a plan that focuses on addressing some core issues.

Video: An Example of Prioritizing Needs and Strengths Video transcript: >> So can you give an example of how you have been able to prioritize the needs with the families given the answer that you just gave? >> Just about two years ago I started working with this family. And their son, who was I believe eight years old at the time, he'd been in and out of hospitals and had been in the hospital for about two months at that point in his final hospitalization. And, you know, they came in talking about his anxiety, and his anger, and their disrupted home life, and the effect it was having on his siblings, and the fact that he couldn't participate in any community activities. And, you know, the list just sort of went on and on and on. They really felt like everything just needed to be fixed was the word they kept using. They just wanted it to get better. And so sitting through and going the CANS with them just a couple weeks after he came into the residential center, you know, we're sort of able to see what the biggest areas were and what they felt was really driving everything was his underlying anxiety. So we made that really the focus of the treatment and sort of saw that after that, everything -- all areas -- started getting a little bit better.

Using CANS Ratings in Treatment Planning Voiceover transcript: The complications of a child’s life, like those in Erin’s example, are often very apparent when one talks with a child. Here is an example of the “messiness” that a clinician might encounter when first interviewing a child. Listen to how Nick describes his challenges. Imagine how the CANS would help you sort through these challenges.

Video: Nick’s Needs Video transcript: [ Inaudible ] >> Yeah, we go to Friday Family Support Group. I go there pretty sure to, like, help deal with strategies to not get angry and help with social skills, like, get along with my sister. And yeah. Mostly for me my sister, sometimes my mom and my dad. Mostly my dad and my sister. I usually swear. I usually -- I get angry, throw stuff at people, get in trouble. I don't like about myself sometimes I'm messy -- that's what I hate about me sometimes. I have these little squeaky balls, stress balls, and I squish them to, like, relieve the stress. And at school the school counselor told me to make a figure eight on my hand to relax me for tests and to, like, take deep breaths. Sometimes when I get mad at my mom or dad or sister, I call Dalene and she helps me with what's going on. I don't get angry at school. It's just that I get angry inside, but I don't get angry at -- like, sometimes I just go home and try to let it out on a pillow or something. Yeah. But I only get angry at school. It's like I get stressed in school. So I do that figure eight thing. In third grade I had 800 tardies because I wouldn't wake up. And I would fight with my mom not going to school. But I've only missed three days of school and I only missed two or three days [inaudible] tardies.

CANS Ratings of Needs Voiceover transcript:

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Nick mentioned many challenges: He gets angry with his sister and parents, and when he is angry, he throws things. He has had trouble getting to school on time. He gets very stressed at school. He says he needs help with “social skills.” This is all very important information. But we need to also know about the severity of his anger, stresses, and social skill needs: how often do they occur, how intense are they, what is the potential for harm to self and others? In Nick’s situation, the treatment planning process would evolve from Nick’s insights through conversations with Nick’s caregivers, his school contacts, and current and previous treatment providers. Using CANS as a reference point in all these discussions will help his therapist organize the information. Ratings of 3 will typically rise to top priority, especially where safety is a concern. If Nick’s angry outbursts rate a 3, then his anger issues require priority attention. Ratings of 2 are “actionable” and need to be addressed in treatment, but some will be judged more urgent to the family than others, so prioritization will involve gathering more information through close collaboration. Using the comment sections of the CANS to provide a narrative and context for the reasoning behind your ratings will assist in communicating with others and evaluating priorities.

Use of CANS Ratings: Actionable Items Voiceover transcript: For some needs, there is a clear relationship between what is actionable and what is recommended: For example, actionable ratings on depression could suggest an evidence-based intervention such as Cognitive Behavioral Therapy. Or, if the Caregiver Needs domain scores are high, a family partner might help. The presence of risk behaviors often suggests the need for formal safety planning.

Too Many Actionable Items Voiceover transcript: But what about those situations in which the youth presents many actionable items that cannot be addressed simultaneously? Erin Lechter and Patti Cedrone discuss helping families set priorities through the use of CANS and by focusing on strengths as well.

Video: Prioritizing Needs and Reflecting on Strengths Voiceover transcript: >> So, how do you take the needs that have been identified and prioritized in the CANS assessment and then turn that into a treatment plan? >> I think the biggest thing is - you know, you just used the word prioritizing again, I think - you know, there's often multiple needs for any child, for any family. But a treatment plan with a multitude of goals is just too overwhelming. No one can possibly work on all of that, whether you're the provider or whether you're the client. So, by using the CANS, I think we see where the threes and the twos are that helps to show us where our main focus should be. So, writing up your goals, you're going to include oftentimes the CAN language in both the goals and the objectives under those goals. And then too, you can sort of track that data. Is the child making progress towards those goals and is that then changing the scoring on your CANS if you're going to repeat it? Does it go from a three to a two, or from a two or one, or even up to zero. >> And I think one of the great things about the CANS is that it does assess both strengths and needs. So, we've talked a little bit about the needs. Can you talk about how you have used the strengths that are identified through the CANS in your treatment planning process? >> I think one of the hardest things for families is to recognize the strengths. I think we see them at their

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worst moments, a lot of the time, and they just don't feel like there's anything positive happening. So, in order to get them to really see that going item by item through the CANS is often really oh, you know, we do have a really great family support system. Oh, my child really does like school. You know, there's just a lot of opportunities for them to sort of force them to reflect on what the strengths are, and then building those into the treatment plan as well so that we're not just focusing on what the problems are but we're really trying to build up those strengths and capitalize on them as well. >> Yeah, I think that's a really important point because we do work with multi stressed families and the entire system of care that we have in the commonwealth and there are a lot of families who really don't even recognize that they have strengths. So, sitting down - I can think of families that I worked with when I was with the CSA and really talking about your family does have strengths. I know it feels bad right now and you are asking for support and you do need help but look at all these things you've been doing right. Look at all these things you've been doing well. Look at the relationship you have between yourself and your child or your extended family and natural supports with the schools. And sometimes that's enough to get the family motivated and more engaged in treatment.

Using CANS Ratings in Treatment Planning Voiceover transcript: Needs ratings already suggest starting points for treatment and care planning, but as Patti and Erin concluded, you also have to reflect on strengths. To illustrate this, let’s return to Nick. The video on Nick’s needs showed him playing sports and talking about the coping skills that he uses when he gets stressed at school. But the CANS probes further for Nick’s strengths. You probably recall earlier that we watched a video on Nick’s strengths. The video is repeated here if you’d like to review it again to recall them.

Video: Nick’s Strengths Video transcript: >> I love reading, probably like half -- like half of this shelf already. I just love these. I just love books. They’re so awesome. one of my favorite - my favorite one is this one, it's very funny. It's called Nerds. It's very funny. I like to read Captain Underpants, Diary of a Wimpy Kid. I can't find the book it's 101 ways to like creep your enemies, and parents, or something, out. It's like 101 Ways to Creep Your Parents and Enemies Out, I'm pretty sure. Oh, Just for Boys, this book, it's pretty cool. It's - it like - it's like tells everything just for boys. I'm very good at math, like adding fractions and subtracting fractions, I'm so good at now. I'm multiplying fractions, dividing fractions, equivalent fractions, I'm so good at those, and I’m very good at math so I just - it's one of my favorite subjects because I'm so good at it. And other things, I'm not so good at. My room is so clean because like, I'm a very neat person, I like clean stuff. Like, if something's on the floor, immediately I'll just pick it up. In third grade, I used to play recorder but I'm going to - I'm going - I'm pretty sure I want to do an instrument next year. I want to play the flute. I want to be a cop because they get to arrest people and they have guns and they [inaudible], you can handcuff people, and you get to drive this cool car that has a - in the future, I think we'll have a computer as the stereo in it, I hope, and they go Dunkin Donuts and eat some donuts and coffee. I'm a gamer. I love gaming. I'm not so creative, I've never had that imagination, not that much. But when it comes to Legos, I do. And when it comes to Minecraft to build stuff, I do. I like to dance too, and it helps me like express myself, like my dancing, and my - like, singing or some - whatever I do. My teacher and my - lunch aide are like the nicest people in the whole school, besides me.

CANS Ratings of Strengths

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Voiceover transcript: The exploration of strengths reveals many more facets of Nick – love of reading and dancing, confidence in his math ability, keeping his room neat, and plans to play music and become a policeman. These facets may have been overlooked if the conversation had focused only on his needs. Nick’s interest in sports could be harnessed to learn some social skills, such as taking turns or being gracious in victory or defeat. His hopeful orientation toward the future could be the foundation for developing social connections and friendships through shared interests. But as we have discussed, finding a child’s strengths might be difficult, particularly in times of urgent need. In the next video, Beth Chin asks Anthony Irsfeld for an example of how he gets the family to start thinking about strengths. His answer is a good one.

Video: A Question that Gets to Strengths Video transcript: >> So, I'm wondering, do you have any - have any suggestions on some questions that we could instruct our staff to ask? >> At the risk of sounding glib, I do. I have a favorite question and I recognize that this is - that there's a lot more to be said about how to do this, but just as an example. It's true that some families that you'll work with to ask them about strengths feels disrespectful, they're very worried, they're very concerned. And if you come in with, well, tell me what's great about your kid, it feels like you're really not getting how concerned they are. And you can really turn people off. If you're working with a family that's very focused on the problem and you're feeling like they just aren't wanting to go there, I think a wonderful question to ask is, is this the worst it's ever been and I like this question because no matter the parent says, I have a good follow-up. So, if I say to a dad, is this the worst it's ever been and he says no, six months ago, it was even worse. My follow-up is well, tell me how it's different now. And now, he's going to talk to me about how it's slightly better now, and we've changed the dynamic of that conversation just a little bit. If he says to me, absolutely, it's never been this bad, then my response will be could you tell me what it was like before it got this bad. And then once again, he's describing for me something about his son or daughter that isn't necessarily strengths but we've moved a little bit off of the concern and we're broadening out that description of that child. And that's really the goal of good strength based conversations is to make our conversations more three dimensional and less about simply where they're making bad choices, or where they're struggling, into kind of more of a whole person. who has hopes, and dreams, and talents, and strengths, you know, things that they do well. So, yeah, just as a basic beginning question, is the worst it's been, I think is a wonderful way to help parents who might be very focused on problems to move aside.

Interactive Exercise 4

Interactive Exercise 5

Rating Items and Treatment/Care Planning: Tisha Mini-Vignette Voiceover transcript: Now let’s go over a short vignette. Rate some items based on the information given, and then describe how these ratings might inform a plan for intervention. Please take a couple of minutes to read over the mini-vignette on Tisha. In the next 2 slides, we will rate Tisha on a few items from the Needs and Strengths domains.

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Rating Items and Treatment/Care Planning: Using Needs Domains Voiceover transcript: For Tisha, a rating of 2 was given for Conduct, Oppositional, and Self-Injurious Behavior. All three needs are clearly present and require action, but they are not so severe as to be rated a 3.

Rating Needs Items and Treatment/Care Planning Goals Voiceover transcript: The next table shows goals in Tisha’s treatment or care plan. A general guideline is that without any further information, needs rated a 2 would be included the plan. If she had an item rated as a 3 it would take priority because it suggests immediate action. In this case, action will be taken to decrease her aggression toward her brother, her oppositional behaviors at school, and her skin picking. These goals are stated positively as behavior that everyone is hoping to observe over time.

Rating Items and Treatment/Care Planning: Using Strengths Domain Voiceover transcript: Ratings from the Strength domain also directly affect one’s treatment or care plan. Remember, on the Strengths domain, ratings of 0 and 1 are good. Any of the strengths rated a 0 or 1 could be included in your plan. Here we see the examples of the Optimism and Talents/Interests items, which are both rated 0’s for Tisha.

Rating Strength Items and Treatment/Care Planning Goals Voiceover transcript: In the next table, we see how these strengths are incorporated into achieving Tisha’s goals. They are not just regarded as positives; they can also be used to address a need. For example, using Tisha’s interest in gymnastics, we might examine how this setting differs from the school environment where she is oppositional. Can we tap into the conditions of the gym and work with the teachers to create similar conditions in school? Or can we use her high level of optimism as a motivational bridge to help reduce self-harm?

Rating and Treatment/Care Planning: Another Example – Adi Voiceover transcript: In the next few slides we will rate items from the Needs and Strengths domains based on another short vignette, this time for Adi. Please read the vignette, and think about which items might be rated for Adi and how these ratings will inform his care.

Rating Items and Treatment/Care Planning: Using Needs Domains Voiceover transcript: Again, items that are rated a 2 or 3 in a Needs domain should be included in your treatment or care plan. The items Medication Adherence and Educational Attainment are from the Transition to Adulthood domain, which you should rate, as Adi is 16 years old. Adi’s medication adherence is in need of more support, and action should be taken. Adi’s lack of educational attainment is severe and is rated a 3, as immediate intervention is recommended. We also rated School Attendance and School Achievement from the Life Domain Functioning. Attendance was rated a 1 because the information provided on attendance is not clear enough to know if action should be taken or how severe the need is. Therefore, watchful waiting to gather more information seems warranted. School Achievement, however, is severe, as he is already a year behind and showing signs of falling further behind.

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Rating Needs Items and Treatment/Care Planning for Adi Voiceover transcript: This table includes a goal to increase Adi’s medication compliance and a goal regarding Adi’s educational attainment and school achievement, which will require immediate intervention. This short vignette and the ratings illustrate both the use of the Transition to Adulthood domain and the relatedness of some items on the CANS. This relatedness is to be expected.

Rating Items and Treatment/Care Planning: Using Strengths Domain Voiceover transcript: As always, we want to investigate strengths as well. Here we see the Community Connections and Resiliency items were rated 0 and 2, respectively. Adi's shows Community Connections strength as he regularly plays football with his friends at the community center on weekends. The rating is a 0. Adi also shows some possible resiliency. He fulfills his love for football by playing at the community center after losing his place on the school team. This suggests some resiliency which could be nurtured and thus receives a rating of 2.

Rating Strength Items and Treatment/Care Planning for Adi Voiceover transcript: As we’ve said before, any strengths that are rated a 0 or 1 could be included in Adi’s treatment or care plan. His Community Connections could be a basis for reclaiming connections to school and educational goals. Work will be needed with Adi to increase his awareness that playing football at the community center is an example of resiliency, and to help transfer his resiliency to skills such as medicine adherence.

Using CANS Ratings Over Time Voiceover transcript: One important feature of the CANS is that it is updated at least every 90 days. This may seem like extra work to the busy provider, but each iteration adds to the understanding of the youth and family. Changes in the CANS track progress toward goals. CANS data provide you with a record of the youth’s history. This is powerful information! The next conversation between Risa Sugarman and Bethany D’Amico explains further:

Video: Some Benefits of Rating CANS Over Time Video transcript: >> So the CANS is a really useful tool at intake but what's the benefit of having to redo it every 90 days? >> There are actually many benefits to updating it every 90 days. At the provider level, it's good for a clinician when updating on that - on day 90 to compare that CANS to the initial CANS and see where have the ratings moved. Certainly if you have movement from - with strengths where you had a strength that was rated a 2 and 90 days later, it's rated a 0, that it’s a centerpiece strength, that's very good to know in terms of progress. The same with the needs, if there was a need that was initially rated a 2 and now that's a 1, where you're just watching it, that's measuring progress. And so, over time, every 90 days, the time to take to do that comparison is really important for the clinician, also for your supervisor in terms of monitoring progress, and certainly at the agency level as well.

Collaborating on Progress Voiceover transcript:

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Measuring change over time is essential. It is what keeps hope alive. Families and providers want to know when change has occurred, when a transition is on the horizon, and when treatment is a success. Listen to the following conversation between a mother and a clinician to hear how the therapist describes progress on the CANS, how the mother has observed change, and how these changes suggest huge successes for the child and family!

Video: How Progress Affects a Family Video transcript: >> Looking back at her first CANS, you know rating from 0 to 3, if you remember, there were a lot of 2s and 3s, a lot of things that needed to be addressed. Her most recent CANS barely any. How does that feel looking back and looking over all the progress she's made? >> It's like it's not even the same child. It literally is like not even the same child and it's like the look in her eyes. I had this thing about looking in my children's eyes, I can tell if they're lying. I can tell if they're being honest with, even my oldest son, he's 22. I can look in his eyes and tell him if he's lying through his teeth, you know? And I could just see their emotions in their eyes, and her eyes are different now, you know? When I used to look in her eyes, back in the times where things were more kind of chaotic and frantic, she had this look in her eyes, like help me, you know? Don't you see what I'm trying to tell you? And I had no clue how to help her. But the look in her eyes is different, you know? It's kind of like a light, like we have an understanding, you know, like hope. That's the only thing I could explain before, it was hopeless, and now there's hope. It's only getting better and better; you know? There were some challenges in the beginning but we've worked through them. And if I ever do have a setback or something reoccurs, I know how to readdress the issue and I know how to redirect her. Before, I didn't have those skills, you know? All the pamphlets and, you know, things I tried to do just weren't working, you know? I needed assistance and we're getting that assistance. And it's showing, it's showing. she's the proof that we are getting their assistance, a child that wasn't talking, that was aggressive, that was unable to kind of mix with other children properly. We really didn't go anywhere and it's like the complete opposite.

Collaborating on Lack of Progress Voiceover transcript: Of course, in other families, CANS assessments show minimal progress or even an increase in challenges over time. Such changes are equally important to discuss with the family. Juan, for example, was initially referred for In-Home Therapy. His first CANS showed 2’s in areas of family relationships and emotional needs. These were offset by strengths in community connections. Nine months into IHT treatment, Juan’s family had financial hardships that forced them to move to a neighboring city with a reputation for higher crime, poorer schools, and fewer resources. Community connections were suddenly disrupted for Juan and his family, and the CANS community connection rating changed from a 0 to 3. Family relationships deteriorated. New needs cropped up in school behavior and attendance, as well as community behavior. Most concerning was a spike in Juan’s depression accompanied by a suicidal gesture. These new ratings of 2s and 3s led to major changes in treatment priorities, including level of care decisions. The IHT team, including his family, agreed that Juan would likely benefit from a brief stay in a Community-Based Acute Treatment center and that Intensive Care Coordination could best handle the complex family and clinical needs that were contributing to Juan’s depression.

Measuring Progress: Individual Level Voiceover transcript:

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Such collaboration and communication about progress with the youth and family is the main reason to update CANS every 90 days. Comparing a child’s needs and strengths using the CANS ratings as touchstones helps track progress. For example, when improvement occurs on items rated a 3, the clinician decides whether the rating moves to a 2, a 1, or, in rare cases to a 0. Similarly, when items rated a 2 have improved, the clinician may rate them a 1 or 0 during a reassessment, depending on what has been learned. By examining CANS over time, the clinician and the family can answer questions about the child’s progress. Look at the next set of slides for ideas about how to report data on an individual client.

Measuring Progress, Individual Level: Needs Voiceover transcript: Here is an example of how progress was measured regarding one client, 15-year-old Chad. This table shows Chad’s ratings of needs over the course of 3 CANS assessments during In-Home Therapy, in the Child Behavioral/Emotional Needs domain. A few items show no change; for example, Psychosis has a continued rating of 0 or no evidence at all three points in time. The Anxiety and Oppositional items also show no change, but with ratings of 1 and 2, respectively. Other items show positive change; for example, the Hyperactivity/Impulsivity item was an actionable item rated at a 2 for several months. But by December, the rating was decreased to a 1, or watchful waiting. Substance Abuse was an item that, unfortunately, worsened over time and moved from requiring action (2) to immediate action (3) in September.

Measuring Progress, Individual Level: Strengths Voiceover transcript: This table shows Chad’s ratings over the course of 3 CANS in the Strengths domain. The Family item is an example of a strength that shows no change, as it was an existing strength for Chad on all 3 CANS. The Interpersonal item illustrates a strength that has improved. It began as a potential strength—rated a 2, and by December it had become an existing strength for Chad—rated as a 1. Chad’s Spiritual/Religious ratings also improved and did so rather quickly between the first and second CANS. Fortunately, in Chad’s case, none of his strengths decreased over time.

Member Progress Report Voiceover transcript: This slide shows the kind of report that you will be able to generate automatically with CANS data from the Virtual Gateway. Note at the top that this fictitious child, Alejandro Diaz, was born in 2004, his agency is ABA, he is receiving outpatient services, and the version of CANS that has been used is the 5 through 20 version. You also see that five CANS have been prepared (look at the five dates on the y-axis.). Note that he had a number of needs that required some action for his first CANS, but those that required immediate action were all clustered in the Cultural Considerations domain. See also that these severe needs decreased over time. Although there is still much room for improvement in the Cultural Considerations domain, we observe that discrimination/bias, cultural identities, and agreement about strengths and needs have all been reduced to ratings of 2. Notice also that during the initial CANS very few strengths were identified for Alejandro, but by the last CANS, two new strengths have emerged and four others have potential. Given other positive or neutral changes seen, we would conclude that Alejandro’s life is improving and these kinds of changes would be well worth celebrating with the child and his family.

Measuring Progress: Supervisory Level Voiceover transcript:

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Progress on the CANS may also be used in your discussions with a supervisor. When you are examining an individual child’s progress, the CANS data provide strong summary points for getting input from and collaborating with your supervisor. Likewise, you can compare data across similar youth with your supervisor. Supervisors also might want to examine all of their workers’ CANS and use this information to improve their supervision. In this next clip, Jessica discusses her use of CANS in supervision.

Video: An Example of Using CANS Ratings by a Supervisor Video transcript: >> Initially upon intake we use CANS as comparing it to the comprehensive assessment and making sure the areas of need are matching. So what's marked as twos and threes should really be implemented into the target symptoms that are in the treatment goals. And then from there we use it as a measure of progress. So is what was a three, does that you know, then come down to a two, hopefully a one and so on and so forth. Are they making the changes overall in treatment?

CANS Activity Report: Criteria Selection Form Voiceover transcript: Take a look at another reporting tool that generates reports for multiple workers and multiple youth. The CANS Activity Report was designed for supervisors to review CANS activities by clinician, level of care, and other criteria. Displayed here is an onscreen selection form for this report. Supervisors can review all of the CANS of any status for specific clinicians, groups of clinicians, or level of care. This report displays information by client name, assessment date, CANS status, days since previous CANS, and whether or not it has been more than 90 days since the last CANS was completed.

Measuring Progress: Agency Level Voiceover transcript: Agencies or programs can also download the data from all of their families who have given consent and examine the aggregate data for agency-level decisions. For example, an agency could count the number of youth who were rated a 2 or 3 for the “depression” item on their initial CANS, and then compare to the number of children who are rated 0 and 1 by the third CANS. By reviewing groups of youth on a single item basis, agencies can help assess effectiveness of interventions for specific issues. CANS data also can help with assigning clinicians’ cases based on workload; for example, if one clinician’s caseload has numerous acute ratings (2 or 3), while another clinician has numerous mild ratings (1), cases may be distributed differently. Here Walker Clinical Director Patti Cedrone continues the discussion with Erin Lechter about using CANS data at Walker.

Video: Examples of Using CANS Ratings at the Program Level Video transcript: >> Patti, are there any other ways that you've used the CANS in either individual supervisions or group supervisions with clinicians? >> So there are a variety of ways that the CANS scoring could actually be used in group supervision or even just assessment of an individual clinician. You can use Excel spreadsheets and really track the data. And you can see looking at the different domains and looking at the progress that's being made or if there isn't progress being made. I think as a clinician it's really important for us to really look at what our needs are and the work that we're doing. So if we can identify whether it's one clinician or a group of clinicians or our entire team, that there are specific domains where there is consistent 2s and 3s with minimal progress being made. That's an area that we would look to pursue some additional training for

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our staff. Do we need to bring in additional resources? Is this an opportunity for us to learn and grow as a group of professionals to offer and deliver better services to the kids and families that we're working with.

Interactive Exercise 6

Interactive Exercise 7

Use of CANS Data: Intensity of Services Voiceover transcript: Now that we have reviewed the many uses of CANS, let’s begin to examine how both the CANS data from the initial intake and CANS data over time are used to help determine the intensity and type of services that might be helpful. CANS is a part of the process of assessment, planning, and decision-making. Intervention planning also takes into account the family’s culture and preferences, the knowledge, experience, and judgment of providers, and sometimes, other system mandates. CANS presents evidence of specific factors that can provide direction in determining appropriate services for the youth and family. But remember, services within MassHealth have to meet medical necessity criteria.

CANS Data as Hub Service Indicators: ICC Voiceover transcript: Take for example, Intensive Care Coordination or ICC. ICC is usually indicated for a family whose CANS scores identify more than one actionable item that cannot be addressed by a single program or service. ICC is recommended when the need for Care Coordination becomes challenging for a family. For example, when a youth and family need or receive services from multiple providers, schools, or state agencies; when caregivers need help prioritizing goals and monitoring progress; or when a youth has needs beyond their behavioral health challenges, such as housing, legal problems, or lack of sustainable supports.

CANS Data as Hub Service Indicators: In-Home Therapy Voiceover transcript: For another example, let’s discuss In-Home Therapy or IHT. IHT is indicated, in part, by actionable CANS scores in the following domains: Life Domain Functioning (including home, friends, community, and school); Caregiver Resources and Needs; and Family Stress. IHT is particularly beneficial when CANS ratings suggest that home dynamics are affected by a youth’s behavioral health needs, that caregivers need more urgent or intensive help with their youth’s emotional and behavioral challenges than could be addressed through Outpatient Therapy. Or that the primary need is the family learning new ways to relate to one another, set limits, or regulate behavior.

CANS Data as Hub Service Indicators: Outpatient Therapy Voiceover transcript: Outpatient Therapy responds to needs based on CANS ratings related to: Behavioral/Emotional Needs, Risk Behaviors, and Caregiver Mental Health. Outpatient Therapy provides therapeutic intervention to children and youth in need of mental health resources, and may include individual, family, and group therapies. It addresses a variety of behavioral health issues that significantly interfere with functioning in at least one area of the child’s life.

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Use of CANS Data: Hub-Dependent Services Voiceover transcript: Because CANS organizes information and offers a way to monitor change, it is important for Hubs to share CANS data with other providers, including those providing Hub-dependent services. For example, CANS ratings can focus a Therapeutic Mentoring program on the specific actionable needs that are relevant to their work with a youth. CANS data can identify strengths that a Family Partner might use in working with a parent. Subsequent CANS ratings highlight progress or setbacks to suggest changes in services. For example, progress might indicate that ICC is no longer needed. Or worsening CANS scores in particular domains might trigger the addition of In-Home Behavioral Services.

Transition Planning Voiceover transcript: In general, when strengths go up and needs go down, it is time to consider transitioning to a less intensive level of care, say, moving from Intensive Care Coordination to the level of coordination included in IHT, or ending IHT in favor of Outpatient Therapy. When strengths and needs change such that action is no longer necessary, then you might consider transitioning the family from formal services to community- and family-based supports.

Transition Planning: Progress is Not Linear Voiceover transcript: At other times, needs may increase, or strengths may become weaker. And, as progress isn’t linear, it’s important to monitor CANS ratings closely and examine how changes in the child’s needs and strengths might suggest additional services or supports. Regular monitoring also makes it likely that more people have input on the child’s needs and strengths, and that everyone keeps focused on changes when they occur. Here is what Jack Simons says about how reviewing CANS at least every 90 days can help:

Video: Reviewing CANS Every 90 Days Video transcript: >> Can you tell some of the ways that the CANS could help monitor treatment outcomes for families? >> The CANS does need to be refreshed every 90 days. I guess we would recommend that you should be monitoring outcomes much more frequently than 90 days. That's sort of the outside and really every week you should be checking in with the family to find out how are things going and specifically how are things going on the items that are priorities for you? But even if you go to that 90 day level, I think the CANS can be useful partly because it really can reflect the point of view of more than one individual. So it's a conversation with the family and it can be also a conversation with other providers. And what we know about how people report about kids is different people have different takes on a child. So there are discrepancies among different informants who relate to that child. The teacher. The parents. The therapist. The child. And possibly other providers. So doing that CANS every 90 days is a great opportunity to try to coordinate those perspectives. And if I'm working with a family, it's much more valuable for me to hear about other people's perceptions of outcomes than just relying on my own perceptions. So I think that repetitive. It may seem repetitive sometimes but the real question is about change. Is there new information that we need to incorporate into a change in our treatment plan? And that's where I think the CANS can really help.

Transition Discussion With Families

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Voiceover transcript: As with all decision-making around treatment, transitions require an honest discussion with a clear rationale to help ensure that all members of the team – in particular the family – are on the same page. The CANS ratings, shared throughout services with the family, can guide this discussion. The CANS serves this purpose not just with CBHI service transitions, but also with major changes in state agencies, and other linkages. In the next video John Kelty describes using CANS as a youth is preparing to leave residential care provided through Caring Together.

Video: An Example of Transitions from Caring Together Video transcript: >> So how is CANS used to help inform transition planning for children and families to help ensure they get the services they need when they return back home to the community? >> As part of Caring Together, Caring Together providers of residential services are required to do a CANS. Conduct a CANS with the youth and family as part of the discharge planning process. So before they leave, it's part of that process to conduct a CANS. The nice thing about that is that it gives the youth and the family and the provider an opportunity, a structured opportunity, to kind of review how things have gone. To review what are the needs that were identified in the beginning that have had improvement. What are new needs that have appeared that were not being -- had not been identified earlier on and what kind of strengths and resources are now available that may not have been available in the first time around at the front door. So it's a great opportunity for everyone to sit back, think together, and engage the youth and the family in that process as they make the plan for the next steps.

Transition Planning: Agreement, Clarity, and Responsibility Voiceover transcript: Good transition planning is characterized by: agreement among stakeholders around the family, clarity about the reasons for transition, and agreement about who can respond to what aspect of any ongoing needs. CANS ratings build agreement among team members through a common language about strengths and needs. CANS ratings bring clarity by applying data to the discussion. The CANS supports decisions about who, what providers, state agency, or other helper, is responsible to respond to which area of need.

Interactive Exercise 8

Interactive Exercise 9

Some Final Thoughts About CANS in Daily Practice Voiceover transcript: It is getting late in the training, but we have a few more points for you to consider. We all know that all CANS conversations with youth and family require sensitivity, but certain discussions call for extra care. As we heard when discussing strength-based practices, sometimes everyone is so focused on the child’s needs that questions about strength seem to be off topic. Explaining why strengths questions are asked is essential in these situations. For another example, discussing caregiver needs is often difficult, but it is an important way to show appreciation for the whole family’s situation. A useful practice is to explain why you are asking questions about the caregivers in order to understand the family’s circumstances. Cultural questions also may be hard to talk about, especially when the conversation is between a clinician and family member who differ in gender or race or ethnicity.

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Too much to do, too little time! Voiceover transcript: And now for the questions we get most often, particularly from Outpatient providers: How can I complete the CANS accurately and consistently when I have so much to do and so little time to do it? John Lyons, the developer of CANS, begins to address this in answering Hannah Karpman’s questions about this issue. This is what he has to say:

Video: The Time it Takes to Do the CANS Video transcript: >> So when I'm out in the field I hear a lot from outpatient providers about the challenges of doing CANS in that kind of setting. And I'm wondering if you have any insight or thoughts from other places in the country about that. >> So we collect complaints and the number one complaint about the CANS is it's too long. It takes too much time. We don't have enough time to get the information. And so if you start thinking about time, there's actually three components of time that are relevant and thinking about the CANS. The first component of time is the time it takes to learn the CANS. So it'll take some time to learn how to do it. Standard training is about a day but the reality of it is the training is kind of preparing you to learn it. So it's really a language. It's a second language and as you know, the way you learn language is immersion. So most people say it takes somewhere around five to 10 times doing it before you become familiar with the CANS. The second time consideration is the time it takes to fill out the CANS. If you're a first responder, you're not going to be able to CANS done in a 45-minute hour. It's not going to happen. Now if you have somebody else's CANS and you're updating it, though that's maybe anywhere between two to 20 minutes. The real time is the time it takes to understand somebody enough to be able to fill out the CANS. >> So the question I would ask providers is what's on the Massachusetts CANS that they don't need to understand? And my guess is, if you look at the Massachusetts CANS, there's nothing on it that you don't actually need to know if you're doing your job. If you're a first responder though, you need to give yourself enough time to get to know the family well enough in order to have the information to complete the CANS.

Adequate Training and Experience Voiceover transcript: So let’s examine the three components of time that John talks about. The first is training time. Adequate training on the administration and use of CANS will help clinicians to complete the CANS much more efficiently. We hope the training you are receiving here helps in this regard. We have provided it online rather than requiring you to travel to workshops, so that you can use it when and how it best fits your work schedule. And we have tried to provide you with only the most important training from your perspective as a busy practitioner. Clinicians who become more experienced also become more adept and fluent at completing the CANS.

Accessing CANS Completed by Others Voiceover transcript: In many cases, one of the big time savers is allowing clinicians to access CANS completed by other providers. But this requires adequate understanding of consent. If given consent by the caregiver or

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young adult, the clinician can use previous CANS as a starting point for their own assessment, by copying the previous CANS, making any changes, and saving it to the Virtual Gateway. The use of consent and access to the Virtual Gateway allows clinicians to proceed without reinventing the wheel with families. We provide training on consent and the Virtual Gateway later in these modules.

Integrating CANS and MSDP Forms Voiceover transcript: Another small time saver is that clinicians can skip seventeen items on the Massachusetts Standardized Document Project (MSDP) Child and Adolescent Comprehensive Assessment form if the CANS has been completed with narratives. This can reduce the amount of time it takes to document a comprehensive assessment.

Finalizing Incomplete CANS Voiceover transcript: There also is some flexibility built into completing the CANS. Many providers report that they cannot finish a CANS and they waste their time trying to figure what to do. Sometimes you run out of time in the session, sometimes the family doesn’t return, often the conversation with the family meanders around and doesn’t follow the order of the CANS items, and often you do not obtain all the information you need to make a sound judgment even after a couple of sessions. In the next video Tom Butero answers Tressa Roger’s questions about dealing with these situations.

Video: Managing Incomplete Information Video transcript: >> So, what happens if I'm missing information or I have a difficult time completing the CANS? Sometimes I'll do an initial session with the client, they may not show up again. Sometimes I'm a new provider for a family, they come in, we're building a therapeutic relationship, they don’t want to disclose everything right away. They want to get to know me first. What if I don't have complete information to complete the tool? >> Depends on the circumstance -- if the family doesn't return and we know that happens. You know, they'll come in for the first session and then you never see them again. If you don't have enough information in that first session to complete the CANS, you can just indicate - you can save the CANS literally as being incomplete. And then you can notate in the comment section; that family did not return, and that's perfectly legitimate. The other thing to understand also is you don't have to do it in order. In other words, you don't have to go 1, 2, 3, 4. You can go 1, 6, 9, 12. You do need to complete the whole thing but if there's a flow, for example, to the conversation you're having with the family that doesn't fit with the flow of the CANS, that’s okay, go with that. Finish the areas that you've discussed, you know, in the order that you and the family are discussing them and then score the CANS accordingly. But, like I say, you do have to make sure that you complete the whole thing. When in doubt, sometimes a clinician - you run into a situation, either you don't have enough information even after two sessions, or you just don't feel like you are comfortable scoring a certain area, you can - depending on the situation and the area - you can score it as a zero and then come back to it next time when you do the subsequent CANS. And say oh, I scored a zero here, now I got enough information I think I - you know, I can legitimately give that a different score. So, there's ways to address those kinds of things. I also recommend people sit down - you know, if you're having trouble completing the CANS after even the second session, sit with your supervisor. You know, go over your notes from the session, talk to your supervisor about what you and the family discussed and perhaps the supervisor can help you with

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scoring the CANS a well. So, those are some ways you could do it.

Individual Programs and Agencies Voiceover transcript: Individual agencies and programs also are likely to have policies and procedures in place to address these issues as they arise. As Tom suggested, supervisors can assist workers with overcoming barriers to CANS completion.

What Information Do You Need to Serve Your Clients? Voiceover transcript: The final time commitment that John Lyons talks about is the relation between CANS and understanding children and their families. As he asked: What information do you need to do your job? We think all of the following CANS functions help us do our jobs serving children and families: CANS provides a way to organize information as part of a clinical assessment. CANS provides a framework for communicating youth and family strengths and needs. The shared language of CANS helps you collaborate with your colleagues. The summary data reported in CANS assists with your understanding of the youth and family. When you combine your ratings on the CANS items with the family’s cultural context, and with your clinical knowledge, judgment, and experience, you have a good foundation for doing your job. Most importantly CANS helps you offer a clear, straightforward framework for inviting family perspective and communicating with them throughout the process of care. We end this section of the CANS training with the following video where John addresses Hannah’s questions about being efficient.

Video: Choosing to Use CANS as Part of Your Practice Video transcript: >> You can view the CANS as paperwork, right? This is something I got to fill out because somebody's forcing me to fill it out, right? Or you can view it as a strategy that helps you be more effective. And both are true and it's a personal choice of how people choose to treat it. I collect - as part of a hobby, I collect sayings that I find simultaneously stupid and profound. And so my current favorite is if you use it, it's useful, stupid and profound, right? And so - but that's the CANS, right? If it you use it, it's useful. If you don't - if you just fill out as a form, it's not very useful. But if you embed it in your work, and embed it in your practice, and embed it as a way you communicate with families, with supervisors, with programs, with the state, then you have a different kind of situation because you then have the potential to keeping the conversation about the people we serve. And I think that changes the system fundamentally because the system, historically, hasn't really been enough for the people we serve, only at the clinical level and you're trying to bring it up to the entire conversation's always about that and so I think that's the opportunity.

End of Module