1 Toward a better understood and Toward a better understood and implemented Wraparound implemented Wraparound A topical discussion on A topical discussion on the ‘National Wraparound the ‘National Wraparound Initiative’ Initiative’ Jane Adams, Eric Bruns, Trina Jane Adams, Eric Bruns, Trina Osher Osher, , Janet Walker, Jim Janet Walker, Jim Rast Rast, Nancy , Nancy Koroloff Koroloff, , Pat Miles, John VanDenBerg, and the Pat Miles, John VanDenBerg, and the National Wraparound Initiative advisory National Wraparound Initiative advisory group group 17 17 th th Annual System of Care Research Annual System of Care Research Conference, Tampa, FL Conference, Tampa, FL March 1, 2004 March 1, 2004 National Wraparound Initiative 2 WA’s role within Systems of Care WA’s role within Systems of Care SYSTEMS OF CARE (PHILOSOPHY) Least restrictive Comprehensive array Families as full partners Individualized Care management Culturally competent Smooth transitions to adult system Early identification and intervention Advocacy WRAPAROUND (OPERATIONAL) Strengths based Natural supports Outcome based Flexible resources Family voice and choice Unconditional care Team-based Mental health Social services Education Health Services Vocational Services Recreation Integrated systems National Wraparound Initiative 3 System-of-Care Program Theory Model THEN INTERMEDIATE OUTCOMES Partnerships are broadened and deepened Comprehensive, coordinated, efficient, and accountable system of care is developed Service delivery is enhanced ! ! ! ! ! ! Clinical and functional outcomes for children and adolescents are improved Child and family satisfaction are improved Service system costs are decreased Increased awareness of system-of-care benefits ! ! ! ! ! ! ! ! SYSTEM LEVEL INTERVENTION LEVEL CHILD, FAMILY, AND COMMUNITY LEVEL AND THEN AND THEN Service providers integrate system-of- care principles into practice Children and families receive effective services and supports ! ! ! ! AND IF Activities and outcomes are evaluated at local and national level THEN RESOURCES CMHS funds are provided to communities Matching funds are identified Field-based, practice-driven technical assistance is provided Awareness of system-of- care options is communicated to variety of audiences ! ! ! ! ! ! ! ! AND IF PROGRAM ACTIVITIES Site enhances system of care infrastructure based on interagency collaboration Site builds comprehensive array of community -based services Site provides services tailored to the individual needs of child and family Site enhances family involvement at system and service delivery levels Site enhances cultural competence Performance measures are established ! ! ! ! ! ! ! ! ! ! ! ! ULTIMATE OUTCOMES System of Care Improved Enhanced Reform System of Care Sustained CONTINUOUS QUALITY IMPROVEMENT National Wraparound Initiative 4 Potential Contribution of WA to Potential Contribution of WA to effectiveness of systems of care effectiveness of systems of care Research on Research on systems change initiatives systems change initiatives has found null or equivocal outcomes has found null or equivocal outcomes – Ineffectiveness of individual services Ineffectiveness of individual services delivered delivered – “Logic chain too long” = processes not in “Logic chain too long” = processes not in place to ensure SOC principles are activated place to ensure SOC principles are activated for individual families for individual families National Wraparound Initiative 5 System-of-Care Program Theory Model THEN INTERMEDIATE OUTCOMES Partnerships are broadened and deepened Comprehensive, coordinated, efficient, and accountable system of care is developed Service delivery is enhanced ! ! ! ! ! ! Clinical and functional outcomes for children and adolescents are improved Child and family satisfaction are improved Service system costs are decreased Increased awareness of system-of-care benefits ! ! ! ! ! ! ! ! SYSTEM LEVEL INTERVENTION LEVEL CHILD, FAMILY, AND COMMUNITY LEVEL AND THEN AND THEN Service providers integrate system-of- care principles into practice Children and families receive effective services and supports ! ! ! ! AND IF Activities and outcomes are evaluated at local and national level THEN RESOURCES CMHS funds are provided to communities Matching funds are identified Field-based, practice-driven technical assistance is provided Awareness of system-of- care options is communicated to variety of audiences ! ! ! ! ! ! ! ! AND IF PROGRAM ACTIVITIES Site enhances system of care infrastructure based on interagency collaboration Site builds comprehensive array of community -based services Site provides services tailored to the individual needs of child and family Site enhances family involvement at system and service delivery levels Site enhances cultural competence Performance measures are established ! ! ! ! ! ! ! ! ! ! ! ! ULTIMATE OUTCOMES System of Care Improved Enhanced Reform System of Care Sustained CONTINUOUS QUALITY IMPROVEMENT National Wraparound Initiative 6 Potential Contribution of WA to Potential Contribution of WA to effectiveness of systems of care effectiveness of systems of care Research has found poor outcomes for Research has found poor outcomes for treatments and treatments and EBPs EBPs delivered in “usual care” delivered in “usual care” settings settings Less impact of evidence Less impact of evidence-based based treatments for treatments for children with multiple problem areas children with multiple problem areas (comorbidity comorbidity) and families with complex needs ) and families with complex needs (Jensen, 2004) Jensen, 2004) – Lack of “fit” between family needs and Lack of “fit” between family needs and services/supports provided services/supports provided – Lack of engagement of families Lack of engagement of families – Lack of engineering of program and system Lack of engineering of program and system environment to support environment to support flexible, individualized care flexible, individualized care Presented at the 17th Annual RTC Conference, Tampa FL, 2/29 – 3/3 2004. For more information, contact Eric Bruns: [email protected]
Transcript
1
Toward a better understood and Toward a better understood and implemented Wraparoundimplemented Wraparound
A topical discussion onA topical discussion on the ‘National Wraparound the ‘National Wraparound Initiative’Initiative’
Jane Adams, Eric Bruns, Trina Jane Adams, Eric Bruns, Trina OsherOsher, , Janet Walker, Jim Janet Walker, Jim RastRast, Nancy , Nancy KoroloffKoroloff, , Pat Miles, John VanDenBerg, and the Pat Miles, John VanDenBerg, and the National Wraparound Initiative advisory National Wraparound Initiative advisory groupgroup
1717thth Annual System of Care Research Annual System of Care Research Conference, Tampa, FLConference, Tampa, FLMarch 1, 2004March 1, 2004
National Wraparound Initiative 2
WA’s role within Systems of CareWA’s role within Systems of CareSYSTEMS OF CARE
(PHILOSOPHY)Least restrictive
Comprehen
sive a
rray
Families as full partners
Individualized
Care management
Cultu
rally
com
pete
nt
Smooth transitions to adult system
Early identification and
intervention
Advocacy
WRAPAROUND (OPERATIONAL)
Strengths based Natural supports
Outcome based Flexible resources
Family voice and choiceUnconditional care
Team
-bas
ed
Mental health
Social services
EducationHealth
Services
Vocational Services
Recreation Integrated systems
National Wraparound Initiative 3
System-of-Care Program Theory Model
THEN
INTERMEDIATE OUTCOMES
Partnerships are broadened and deepened
Comprehensive, coordinated, efficient, and accountable system of care is developed
Service delivery is enhanced
!!
!!
!!
Clinical and functional outcomes for children and adolescents are improved
Child and family satisfaction are improved
Service system costs are decreased
Increased awareness of system-of-care benefits
!!
!!
!!
!!
SYSTEMLEVEL
INTERVENTIONLEVEL
CHILD, FAMILY, AND COMMUNITY LEVEL
ANDTHEN
ANDTHEN
Service providers integrate system-of-care principles into practice
Children and families receive effective services and supports
!!
!! AND IFActivities and outcomes are evaluated at local and national level
THEN
RESOURCES
CMHS funds are provided to communities
Matching funds are identified
Field-based, practice-driven technical assistance is provided
Awareness of system-of-care options is communicated to variety of audiences
!!
!!
!!
!!
AND IF
PROGRAM ACTIVITIES
Site enhances system of care infrastructure based on interagency collaboration
Site builds comprehensive array of community -based services
Site provides services tailored to the individual needs of child and family
Site enhances family involvement at system and service delivery levels
Site enhances cultural competence
Performance measures are established
!!
!!
!!
!!
!!
!!
ULTIMATE OUTCOMES
System of Care Improved
Enhanced Reform
System of Care Sustained
CO
NT
INU
OU
S Q
UA
LIT
Y IM
PR
OV
EM
EN
T
National Wraparound Initiative 4
Potential Contribution of WA to Potential Contribution of WA to effectiveness of systems of careeffectiveness of systems of care
Research on Research on systems change initiativessystems change initiativeshas found null or equivocal outcomeshas found null or equivocal outcomes–– Ineffectiveness of individual services Ineffectiveness of individual services
delivereddelivered
–– “Logic chain too long” = processes not in “Logic chain too long” = processes not in place to ensure SOC principles are activated place to ensure SOC principles are activated for individual familiesfor individual families
National Wraparound Initiative 5
System-of-Care Program Theory Model
THEN
INTERMEDIATE OUTCOMES
Partnerships are broadened and deepened
Comprehensive, coordinated, efficient, and accountable system of care is developed
Service delivery is enhanced
!!
!!
!!
Clinical and functional outcomes for children and adolescents are improved
Child and family satisfaction are improved
Service system costs are decreased
Increased awareness of system-of-care benefits
!!
!!
!!
!!
SYSTEMLEVEL
INTERVENTIONLEVEL
CHILD, FAMILY, AND COMMUNITY LEVEL
ANDTHEN
ANDTHEN
Service providers integrate system-of-care principles into practice
Children and families receive effective services and supports
!!
!! AND IFActivities and outcomes are evaluated at local and national level
THEN
RESOURCES
CMHS funds are provided to communities
Matching funds are identified
Field-based, practice-driven technical assistance is provided
Awareness of system-of-care options is communicated to variety of audiences
!!
!!
!!
!!
AND IF
PROGRAM ACTIVITIES
Site enhances system of care infrastructure based on interagency collaboration
Site builds comprehensive array of community -based services
Site provides services tailored to the individual needs of child and family
Site enhances family involvement at system and service delivery levels
Site enhances cultural competence
Performance measures are established
!!
!!
!!
!!
!!
!!
ULTIMATE OUTCOMES
System of Care Improved
Enhanced Reform
System of Care Sustained
CO
NT
INU
OU
S Q
UA
LIT
Y IM
PR
OV
EM
EN
T
National Wraparound Initiative 6
Potential Contribution of WA to Potential Contribution of WA to effectiveness of systems of careeffectiveness of systems of care
Research has found poor outcomes for Research has found poor outcomes for treatments and treatments and EBPsEBPs delivered in “usual care” delivered in “usual care” settingssettingsLess impact of evidenceLess impact of evidence--basedbased treatments for treatments for children with multiple problem areas children with multiple problem areas ((comorbiditycomorbidity) and families with complex needs ) and families with complex needs ((Jensen, 2004)Jensen, 2004)–– Lack of “fit” between family needs and Lack of “fit” between family needs and
services/supports providedservices/supports provided–– Lack of engagement of familiesLack of engagement of families–– Lack of engineering of program and system Lack of engineering of program and system
environment to support environment to support flexible, individualized careflexible, individualized care
Presented at the 17th Annual RTC Conference, Tampa FL, 2/29 – 3/3 2004. For more information, contact Eric Bruns: [email protected]
2
National Wraparound Initiative 7
Wraparound Process Wraparound Process PrinciplesPrinciples
Prevalence of “Wraparound”Prevalence of “Wraparound”
Estimated 200,000 youth engaged in Estimated 200,000 youth engaged in services delivered via Wraparound services delivered via Wraparound approach (approach (FawFaw, 1999), 1999)
Recent survey found 42 of 46 State Mental Recent survey found 42 of 46 State Mental Health liaisons report Wraparound Health liaisons report Wraparound approach being used in their state approach being used in their state (Burchard, 2002)(Burchard, 2002)
Majority of CMHSMajority of CMHS--funded Systems of Care funded Systems of Care sites report utilizing Wraparound processsites report utilizing Wraparound process
National Wraparound Initiative 9
The Fidelity Problem in The Fidelity Problem in WraparoundWraparound
“Values speak” substitutes for concrete practice “Values speak” substitutes for concrete practice stepssteps
Many things are referred to as WraparoundMany things are referred to as Wraparound
Lacking consistent standards, description of Lacking consistent standards, description of provider practices, and accompanying measuresprovider practices, and accompanying measures
Results in Results in –– Confusion for families, staff, communitiesConfusion for families, staff, communities
–– Many programs achieving poor outcomesMany programs achieving poor outcomes
–– A poorly developed research base overallA poorly developed research base overall
National Wraparound Initiative 10
Growth of Wraparound Literature BaseGrowth of Wraparound Literature BaseNumber of citations, by databaseNumber of citations, by database
0
20
40
60
80
100
PsychInfo 2 12 67
SocWkAb 0 1 9
ERIC 0 1 19
TOTAL 2 14 95
<1990 91-95 96-2002
National Wraparound Initiative 11
Improving outcomes for children Improving outcomes for children with EBD with EBD Integrated treatments citedIntegrated treatments cited11
Functional Family Functional Family TherapyTherapy
WraparoundWraparound processprocess
1In order of development of the research base
National Wraparound Initiative 12
Clinic/community Intervention Development and Deployment Model
Clinic/community Intervention Clinic/community Intervention Development and Deployment ModelDevelopment and Deployment Model
Dissemination, quality, and sustainability within new organizations, settings, & communities
Step 8
Assessment of goodness-of-fit within the host organization, practice setting, or community
Step 7
Effectiveness of treatment variations, effective ingredients, moderators, mediators, and costs
Step 6
Full test of the effectiveness under everyday practice conditions, including cost effectiveness
Step 5
Initial effectiveness test, modest in scope and costStep 4
Single-case applications in practice setting with progressive adaptations to the protocol
Step 3
Initial efficacy trial under controlled conditionsStep 2
Theoretically and clinically informed construction, refinement, and manualizing of the protocol
Step 1
Presented at the 17th Annual RTC Conference, Tampa FL, 2/29 – 3/3 2004. For more information, contact Eric Bruns: [email protected]
3
National Wraparound Initiative 13
CHALLENGECHALLENGE
Bringing rigor and standardization to a Bringing rigor and standardization to a widespread and widespread and compellingcompelling practice for practice for which multiple innovations have been which multiple innovations have been created but not compiled into a fully created but not compiled into a fully described model…described model…
–– To provide the field with a better To provide the field with a better understanding about what high quality understanding about what high quality wraparound iswraparound is
–– To provide the field with a better To provide the field with a better understanding of what is required to do highunderstanding of what is required to do high--quality wraparoundquality wraparound
–– To allow for better evaluation of To allow for better evaluation of wraparound’s impactwraparound’s impact
E.g., determineE.g., determine indicators of highindicators of high--quality quality wraparoundwraparound implementationimplementation
–– To allow for replication of wraparound To allow for replication of wraparound process models that are found to have process models that are found to have positive impactpositive impact
–– To bring providers, trainers, researchers, To bring providers, trainers, researchers, parents/ advocates together into a learning parents/ advocates together into a learning and sharing and sharing communitycommunity
Proposed outputsProposed outputs–– Agreed upon Agreed upon definitions and terminologiesdefinitions and terminologies for for
the wraparoundthe wraparound processprocess
–– Agreed upon description of the Agreed upon description of the wraparound wraparound principlesprinciples, specified for a team and family, specified for a team and family
–– EmpiricalEmpirical-- and theoryand theory--based based rationalerationale for for the the practicespractices employed in employed in wraparoundwraparound (from (from multiple disciplines)multiple disciplines)
–– Clear description of a Clear description of a stepwisestepwise wraparoundwraparoundprocessprocess
Proposed outputsProposed outputs–– RequiredRequired practices within each steppractices within each step (Practice (Practice
Standards)Standards)E.g., within Engagement phase, a “Strengths E.g., within Engagement phase, a “Strengths Discovery Process”Discovery Process”
–– Flexible set of Flexible set of practicepractice optionsoptions for each stepfor each stepE.g., Different means of conducting a “strengths E.g., Different means of conducting a “strengths inventory”inventory”
–– Required Required supports for teams and providerssupports for teams and providers(System and Organizational Standards)(System and Organizational Standards)
With Strategies for achieving these conditionsWith Strategies for achieving these conditions
Presented at the 17th Annual RTC Conference, Tampa FL, 2/29 – 3/3 2004. For more information, contact Eric Bruns: [email protected]
Initiative MethodsInitiative MethodsActive engagement with innovators and trainers Active engagement with innovators and trainers nationallynationally–– Nominate specific procedures and practicesNominate specific procedures and practices
–– Contribute specific frameworks and approaches to Contribute specific frameworks and approaches to ensuring highensuring high--quality wraparoundquality wraparound
NationalNational Advisory group: 60 membersAdvisory group: 60 membersSet priorities for needed productsSet priorities for needed products
Participate in consensusParticipate in consensus--buildingbuilding
Review process, products, and outputsReview process, products, and outputs
WebWeb--enabledenabled Delphi processDelphi process
National Wraparound Initiative 22
National Initiative participantsNational Initiative participants
Core Coordinating
Group
National Innovators and Trainers
National Advisory Group
National Wraparound Initiative 23
Developing TechnologiesDeveloping Technologiesfrom which we can borrowfrom which we can borrow
Effectiveness of treatments for specific problemsEffectiveness of treatments for specific problems
Common ingredients of evidenceCommon ingredients of evidence--based based practices (practices (ChopitraChopitra))
Effective methods for engaging families and Effective methods for engaging families and developing selfdeveloping self--efficacy (McKay, efficacy (McKay, HeflingerHeflinger))
Characteristics of effective organizational Characteristics of effective organizational cultures (cultures (GlissonGlisson))
Engineering system and organizational contexts Engineering system and organizational contexts to enhance diffusion of treatments and to enhance diffusion of treatments and processes (e.g., processes (e.g., SchoenwaldSchoenwald))
National Wraparound Initiative 24
More informationMore information
CoCo--coordinatorscoordinators–– Eric Bruns Eric Bruns –– [email protected]@psych.umaryland.edu, ,
