6 th Annual CANS Conference Betty Walton, Vicki S. Effland & Eric Bruns San Francisco, CA April 20, 2010 Relationship of Fidelity to Wraparound and Outcomes.

6 th Annual CANS Conference Betty Walton, Vicki S. Effland & Eric Bruns San Francisco, CA April 20, 2010 Relationship of Fidelity to Wraparound and Outcomes for Youth and Families

Objectives Effective implementation of research based practices Relationship of fidelity to Outcomes Case Study: Implementation of Wraparound in Indiana Next Steps

What is Wraparound? Wraparound is a family-driven, youth guided, team-based process for planning and implementing services and supports. Through the wraparound process, teams create plans that are geared toward meeting the unique and holistic needs of children and youth with complex needs and their families. The wraparound team members (e.g., the identified youth, his or her parents/caregivers, other family members and community members, mental health professionals, educators, and others) meet regularly to implement and monitor the plan to ensure its success.

For which children and youth is the wraparound process intended? Youth with needs that span home, school, and community Youth with needs in multiple life domains (e.g., school, employment, residential stability, safety, family relationships, basic needs) Youth for whom there are many adults involved and they need to work together well for him or her to succeed

For which youth in a system of care? 80% 15% Most Intensive intervention level Prevention and Universal Health Promotion Level Targeted Intervention Level 2% 3% Full Wraparound Process Less complex needs More complex needs Targeted and Individualized Services

What is wraparound intended to achieve? Basing plans on strengths, needs, and culture leads to more complete engagement of families High-quality teamwork and flexible funds leads to better plans, better fit between family needs and supports, and greater integration of effort by helpers = Greater relevance, less dropout, better follow-through As family works with a team to solve its own problems, develops family members skills and self-efficacy Process focuses on developing supportive relationships Focus on setting goals and measuring outcomes leads to more frequent problem-solving, more effective plans, greater success

What is the research base? Nine Published Controlled Studies of Wraparound StudyTarget populationControl Group DesignN 1. Hyde et al. (1996)*Mental healthNon-equivalent comparison69 2. Clark et al. (1998)*Child welfareRandomized control132 3. Evans et al. (1998)*Mental healthRandomized control42 4. Bickman et al. (2003)*Mental healthNon-equivalent comparison111 5. Carney et al. (2003)*Juvenile justiceRandomized control141 6. Pullman et al. (2006)*Juvenile justiceHistorical comparison204 7. Rast et al. (2007)*Child welfareMatched comparison67 8. Rauso et al. (2009)Child welfareMatched comparison210 9. Mears et al. (2009) MH/Child welfare Matched comparison121 *Included in 2009 meta-analysis (Suter & Bruns, 2009)

Research to Date on Wraparound There have been 9 controlled studies of wraparound published in peer review journals Results consistently indicate superior outcomes for wraparound compared to services as usual* Moderate (ES =.50) effects for living situation outcomes Small medium (ES =.25 -.40) effects for behavioral, functional, and community outcomes These ESs are similar to studies of evidence based therapies and interventions (e.g., MST) as implemented in real world conditions against alternative treatment conditions *Suter, J.C. & Bruns, E.J. (2009). Effectiveness of the Wraparound Process for Children with Emotional and Behavioral Disorders: A Meta-Analysis. Clinical Child and Family Psychology Review, 12, 336-351

We Have Issues. 17 year gap between proving that an approach works and implementation in practice Effective implementation involves multiple factors ( Fixsen, Naoom, Blas, Friedman & Wallace, 2005)

Implementation with High Fidelity Requires County Context and Readiness Staff Selection Training Supervision and Coaching Performance Management Program Evaluation Organizational Supports State Support National Implementation Research Network (NIRN)

Fidelity is critical to outcomes F Higher levels of fidelity to organizational level assessment for ACT was associated with greater reductions in days spent in psychiatric hospitals (McGrew, Bond, Dietzen & Salyers, 1994) F Improved youth delinquency outcomes for higher fidelity Teaching Family model (Kirigin et. al. 1982) F Improved youth delinquency outcomes for higher fidelity MST (Henggler, Melton, Browndino, Scherer & Hanley, 1997) F Better overall outcomes for youth receiving model adherent FFT (Alexander, Pugh, Parsons and Sexton, 2000) F Better outcomes for school-wide behavioral management when implemented with fidelity (Felner et. al. 2001)

Monitoring fidelity of implementation of child and family teams Have facilitators and team members fill out activity checklists Look at plans of care and meeting notes Sit in on and observe team meetings Ask the people who know parents, youth, facilitators, program heads

Wraparound Fidelity Assessment System WFAS WFI-4 TOM CSWI Doc Review WFI-4 Wraparound Fidelity Index CSWI Community Supports for Wraparound Index DRM - Document Review Measure TOM Team Observation Measure

The Wraparound Fidelity Index, version 4 Assesses implementation of the wraparound process through brief interviews with multiple respondents Caregivers Youths Wraparound Facilitators Team Members Found to possess good psychometric characteristics Test-retest reliability Inter-rater agreement Internal consistency Used in research on wraparound Even more widely as a quality assurance mechanism by wrap programs

Wraparound Fidelity Index, v.4 Items on the principles and core activities, organized by the 4 phases of wraparound Engagement: Did you select the people who would be on your youth and family team? Principle = Team based Planning: Does the plan include strategies for helping your child get involved with activities in the community? Principle = Community based Implementation: Does the team evaluate progress toward the goals of the plan at every team meeting? Principle = Outcome based Transition: Will some members of your team be there to support you when formal wraparound is complete? Principle = Persistence

Findings from fidelity research Fidelity-outcomes associations are tenuous and inconsistent at the family/youth level At the site/program level, there is a discernable pattern of WFI Fidelity scores across studies Wraparound vs. non-wraparound programs Wraparound programs with different levels of system support Wraparound programs that achieve better outcomes Beginning to be able to interpret the meaning of WFI scores < 65% = Not wraparound 65 75% = Low average / Borderline 75% - 85% = High average / Acceptable > 85% = High fidelity

Wraparound in Indiana Began in mid- 1990s. 3 CMHI grants State legislation to replicate 2 year development grants Pilot 1915c Medicaid Waiver

Lessons Learned Not EnoughMore Effective Sources inspiring, but Legislation and state policy Targeted funding and contracts Training Persuasion Collaborating with stakeholders (youth & families, providers, systems) Gauging readiness & adjusting tactics Ongoing training, coaching and support Develop adequate infrastructure Monitor progress and use feedback

CA-PRTF Grant Section 6063 of the Deficit Reduction Act of 2005 ( PL 109-171) authorized up to $217 million for a demonstration program for grantee states to use Medicaid funding for home and community-based services as an alternative to psychiatric residential treatment facilities (CA-PRTF). Research Questions. Does the provision of Medicaid-funded home and community based services to youth under this demonstration: Result in the maintenance or improvement in childs functional status? On average, cost no more than anticipated aggregate PRTF expenditures in the absence of the demonstration? National & State Evaluation: IMPAQ & Westat, Project Director, Oswaldo Urdapilleta; Principal Investigator (PI), Garrett Morgan Wraparound 9 States

Evaluation Minimum Data Set Demographic Information Functioning (CANS, CBCL or CAFAS) Fidelity (WFI-4) Services Child Welfare and Juvenile Justice Involvement Youth Services Survey (YSS & YSS-F) Costs + Strengths Based Site Assessment (Effland, 2010)

Indiana Youth Receiving Grant Services with Outcome & Fidelity Measures Jan 2008 - March 31, 2010 660 participants 372 youth had at least one CANS reassessment & a WFI survey Average age = 12.95 years old 71.3% Male 79.2% White 15.7% African American 4.4 % Hispanic

Measuring Improvement Improvement in any Domain Behavioral Health Risks Functioning Strengths Caregiver Reliable Change Index Calculated for Each CANS Domain, p

6 th Annual CANS Conference Betty Walton, Vicki S. Effland & Eric Bruns San Francisco, CA April 20, 2010 Relationship of Fidelity to Wraparound and Outcomes.

Documents

wraparound process

family needs

implementation of wraparound

wraparound intended

wraparound team members

basic needs youth

complex needs

community youth