Top Banner
Individualizing Care Within a Managed Care Context 2006 Training Institutes July 2006 Institute #4 Ray Lederman D.O., CPSA-Tucson Frank Rider, AZ Division of Behavioral Health Services Toni Tramontana, ValueOptions – Maricopa County Robin Trush, System of Care Veteran – Maricopa County
55

AZ CFTs Institute (Orlando, 2006)

Apr 16, 2017

Download

Documents

Frank Rider
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: AZ CFTs Institute (Orlando, 2006)

Individualizing Care Within a Managed Care Context

2006 Training InstitutesJuly 2006

Institute 4

Ray Lederman DO CPSA-Tucson

Frank Rider AZ Division of Behavioral Health Services

Toni Tramontana ValueOptions ndash Maricopa County

Robin Trush System of Care Veteran ndash Maricopa County

Institute 4 Overview

Transforming Managed Care The Arizona System

Structure What Happened Why We Did What We Did

How to Operationalize Results to Date

Change vs Transformation

Definition of ChangeChanger (Old French for ldquochangerdquo) to bend or turn like a tree or vine searching for the sun

Definition of TransformationTransformare (Latin for transform) ldquoto change shaperdquo

Why is Transformation Necessary

Family Dissatisfaction

Fragmented Care

Poor Outcomes

FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES

ARIZONA STATE GOVERNMENT

(Appropriations)

ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

(AHCCCS)

REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)

SUBCONTRACTED PROVIDERS

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

(SAMHSA)

CENTER FOR MEDICARE AND MEDICAID SERVICES

(CMS)

$

$

$

$

$

$

Arizonarsquos Behavioral Health SystemAHCCCS

(State Medicaid Agency)

Arizona Department of Health ServicesBehavioral Health Services

Pascua Yaqui Tribal RBHA

Community Partnership of Southern Arizona

(CPSA)

ValueOptions

Northern Arizona RBHA (NARBHA)

Acute Care Health Plans

Cenpatico BH

Subcontracted Providers

Subcontracted Providers

Subcontracted Providers

Long Term Care Program Contractors

(eg DDD)

Gila River Tribal RBHA

Subcontracted Providers

Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS

TOTALFY 2006 FUNDS

ChildrenrsquosPercent of

Childrenrsquos $MedicaidTitle XIX(674 federal)

$760640800

$269079100

8868

SCHIPTitle XXI(77185 federal)

$15130000

$15130000

499

Federal Grants

$44631300

$10981200

362

County Funds (Maricopa Pima)

$39161500

$1803000

059

State Appropriations

$117516600

$6444600

212

Other

$3778200

0

000

Total Funding

$980858400

$303438500

10000

Behavioral Health Services in Arizona

Statewide enrollment 141393 (children and adults)Statewide children lt18 39020

ValueOptions enrollment 73845

ValueOptions children lt18 20041

Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm

13287

7270

20122

10530

19225

10217

27580

14316

28488

14725

34924

18892

34368

17199

39020

20041

05000

10000150002000025000300003500040000

2000 2002 2004 2006

Arizona T-19Maricopa T-19Arizona TotalMaricopa Total

Rapidly Expanding EnrollmentJune 2000 - June 2006

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 2: AZ CFTs Institute (Orlando, 2006)

Institute 4 Overview

Transforming Managed Care The Arizona System

Structure What Happened Why We Did What We Did

How to Operationalize Results to Date

Change vs Transformation

Definition of ChangeChanger (Old French for ldquochangerdquo) to bend or turn like a tree or vine searching for the sun

Definition of TransformationTransformare (Latin for transform) ldquoto change shaperdquo

Why is Transformation Necessary

Family Dissatisfaction

Fragmented Care

Poor Outcomes

FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES

ARIZONA STATE GOVERNMENT

(Appropriations)

ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

(AHCCCS)

REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)

SUBCONTRACTED PROVIDERS

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

(SAMHSA)

CENTER FOR MEDICARE AND MEDICAID SERVICES

(CMS)

$

$

$

$

$

$

Arizonarsquos Behavioral Health SystemAHCCCS

(State Medicaid Agency)

Arizona Department of Health ServicesBehavioral Health Services

Pascua Yaqui Tribal RBHA

Community Partnership of Southern Arizona

(CPSA)

ValueOptions

Northern Arizona RBHA (NARBHA)

Acute Care Health Plans

Cenpatico BH

Subcontracted Providers

Subcontracted Providers

Subcontracted Providers

Long Term Care Program Contractors

(eg DDD)

Gila River Tribal RBHA

Subcontracted Providers

Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS

TOTALFY 2006 FUNDS

ChildrenrsquosPercent of

Childrenrsquos $MedicaidTitle XIX(674 federal)

$760640800

$269079100

8868

SCHIPTitle XXI(77185 federal)

$15130000

$15130000

499

Federal Grants

$44631300

$10981200

362

County Funds (Maricopa Pima)

$39161500

$1803000

059

State Appropriations

$117516600

$6444600

212

Other

$3778200

0

000

Total Funding

$980858400

$303438500

10000

Behavioral Health Services in Arizona

Statewide enrollment 141393 (children and adults)Statewide children lt18 39020

ValueOptions enrollment 73845

ValueOptions children lt18 20041

Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm

13287

7270

20122

10530

19225

10217

27580

14316

28488

14725

34924

18892

34368

17199

39020

20041

05000

10000150002000025000300003500040000

2000 2002 2004 2006

Arizona T-19Maricopa T-19Arizona TotalMaricopa Total

Rapidly Expanding EnrollmentJune 2000 - June 2006

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 3: AZ CFTs Institute (Orlando, 2006)

Change vs Transformation

Definition of ChangeChanger (Old French for ldquochangerdquo) to bend or turn like a tree or vine searching for the sun

Definition of TransformationTransformare (Latin for transform) ldquoto change shaperdquo

Why is Transformation Necessary

Family Dissatisfaction

Fragmented Care

Poor Outcomes

FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES

ARIZONA STATE GOVERNMENT

(Appropriations)

ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

(AHCCCS)

REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)

SUBCONTRACTED PROVIDERS

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

(SAMHSA)

CENTER FOR MEDICARE AND MEDICAID SERVICES

(CMS)

$

$

$

$

$

$

Arizonarsquos Behavioral Health SystemAHCCCS

(State Medicaid Agency)

Arizona Department of Health ServicesBehavioral Health Services

Pascua Yaqui Tribal RBHA

Community Partnership of Southern Arizona

(CPSA)

ValueOptions

Northern Arizona RBHA (NARBHA)

Acute Care Health Plans

Cenpatico BH

Subcontracted Providers

Subcontracted Providers

Subcontracted Providers

Long Term Care Program Contractors

(eg DDD)

Gila River Tribal RBHA

Subcontracted Providers

Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS

TOTALFY 2006 FUNDS

ChildrenrsquosPercent of

Childrenrsquos $MedicaidTitle XIX(674 federal)

$760640800

$269079100

8868

SCHIPTitle XXI(77185 federal)

$15130000

$15130000

499

Federal Grants

$44631300

$10981200

362

County Funds (Maricopa Pima)

$39161500

$1803000

059

State Appropriations

$117516600

$6444600

212

Other

$3778200

0

000

Total Funding

$980858400

$303438500

10000

Behavioral Health Services in Arizona

Statewide enrollment 141393 (children and adults)Statewide children lt18 39020

ValueOptions enrollment 73845

ValueOptions children lt18 20041

Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm

13287

7270

20122

10530

19225

10217

27580

14316

28488

14725

34924

18892

34368

17199

39020

20041

05000

10000150002000025000300003500040000

2000 2002 2004 2006

Arizona T-19Maricopa T-19Arizona TotalMaricopa Total

Rapidly Expanding EnrollmentJune 2000 - June 2006

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 4: AZ CFTs Institute (Orlando, 2006)

Why is Transformation Necessary

Family Dissatisfaction

Fragmented Care

Poor Outcomes

FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES

ARIZONA STATE GOVERNMENT

(Appropriations)

ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

(AHCCCS)

REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)

SUBCONTRACTED PROVIDERS

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

(SAMHSA)

CENTER FOR MEDICARE AND MEDICAID SERVICES

(CMS)

$

$

$

$

$

$

Arizonarsquos Behavioral Health SystemAHCCCS

(State Medicaid Agency)

Arizona Department of Health ServicesBehavioral Health Services

Pascua Yaqui Tribal RBHA

Community Partnership of Southern Arizona

(CPSA)

ValueOptions

Northern Arizona RBHA (NARBHA)

Acute Care Health Plans

Cenpatico BH

Subcontracted Providers

Subcontracted Providers

Subcontracted Providers

Long Term Care Program Contractors

(eg DDD)

Gila River Tribal RBHA

Subcontracted Providers

Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS

TOTALFY 2006 FUNDS

ChildrenrsquosPercent of

Childrenrsquos $MedicaidTitle XIX(674 federal)

$760640800

$269079100

8868

SCHIPTitle XXI(77185 federal)

$15130000

$15130000

499

Federal Grants

$44631300

$10981200

362

County Funds (Maricopa Pima)

$39161500

$1803000

059

State Appropriations

$117516600

$6444600

212

Other

$3778200

0

000

Total Funding

$980858400

$303438500

10000

Behavioral Health Services in Arizona

Statewide enrollment 141393 (children and adults)Statewide children lt18 39020

ValueOptions enrollment 73845

ValueOptions children lt18 20041

Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm

13287

7270

20122

10530

19225

10217

27580

14316

28488

14725

34924

18892

34368

17199

39020

20041

05000

10000150002000025000300003500040000

2000 2002 2004 2006

Arizona T-19Maricopa T-19Arizona TotalMaricopa Total

Rapidly Expanding EnrollmentJune 2000 - June 2006

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 5: AZ CFTs Institute (Orlando, 2006)

FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES

ARIZONA STATE GOVERNMENT

(Appropriations)

ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

(AHCCCS)

REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)

SUBCONTRACTED PROVIDERS

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

(SAMHSA)

CENTER FOR MEDICARE AND MEDICAID SERVICES

(CMS)

$

$

$

$

$

$

Arizonarsquos Behavioral Health SystemAHCCCS

(State Medicaid Agency)

Arizona Department of Health ServicesBehavioral Health Services

Pascua Yaqui Tribal RBHA

Community Partnership of Southern Arizona

(CPSA)

ValueOptions

Northern Arizona RBHA (NARBHA)

Acute Care Health Plans

Cenpatico BH

Subcontracted Providers

Subcontracted Providers

Subcontracted Providers

Long Term Care Program Contractors

(eg DDD)

Gila River Tribal RBHA

Subcontracted Providers

Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS

TOTALFY 2006 FUNDS

ChildrenrsquosPercent of

Childrenrsquos $MedicaidTitle XIX(674 federal)

$760640800

$269079100

8868

SCHIPTitle XXI(77185 federal)

$15130000

$15130000

499

Federal Grants

$44631300

$10981200

362

County Funds (Maricopa Pima)

$39161500

$1803000

059

State Appropriations

$117516600

$6444600

212

Other

$3778200

0

000

Total Funding

$980858400

$303438500

10000

Behavioral Health Services in Arizona

Statewide enrollment 141393 (children and adults)Statewide children lt18 39020

ValueOptions enrollment 73845

ValueOptions children lt18 20041

Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm

13287

7270

20122

10530

19225

10217

27580

14316

28488

14725

34924

18892

34368

17199

39020

20041

05000

10000150002000025000300003500040000

2000 2002 2004 2006

Arizona T-19Maricopa T-19Arizona TotalMaricopa Total

Rapidly Expanding EnrollmentJune 2000 - June 2006

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 6: AZ CFTs Institute (Orlando, 2006)

Arizonarsquos Behavioral Health SystemAHCCCS

(State Medicaid Agency)

Arizona Department of Health ServicesBehavioral Health Services

Pascua Yaqui Tribal RBHA

Community Partnership of Southern Arizona

(CPSA)

ValueOptions

Northern Arizona RBHA (NARBHA)

Acute Care Health Plans

Cenpatico BH

Subcontracted Providers

Subcontracted Providers

Subcontracted Providers

Long Term Care Program Contractors

(eg DDD)

Gila River Tribal RBHA

Subcontracted Providers

Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS

TOTALFY 2006 FUNDS

ChildrenrsquosPercent of

Childrenrsquos $MedicaidTitle XIX(674 federal)

$760640800

$269079100

8868

SCHIPTitle XXI(77185 federal)

$15130000

$15130000

499

Federal Grants

$44631300

$10981200

362

County Funds (Maricopa Pima)

$39161500

$1803000

059

State Appropriations

$117516600

$6444600

212

Other

$3778200

0

000

Total Funding

$980858400

$303438500

10000

Behavioral Health Services in Arizona

Statewide enrollment 141393 (children and adults)Statewide children lt18 39020

ValueOptions enrollment 73845

ValueOptions children lt18 20041

Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm

13287

7270

20122

10530

19225

10217

27580

14316

28488

14725

34924

18892

34368

17199

39020

20041

05000

10000150002000025000300003500040000

2000 2002 2004 2006

Arizona T-19Maricopa T-19Arizona TotalMaricopa Total

Rapidly Expanding EnrollmentJune 2000 - June 2006

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 7: AZ CFTs Institute (Orlando, 2006)

Arizona BH Funding for ChildrenFUND SOURCE FY 2006 FUNDS

TOTALFY 2006 FUNDS

ChildrenrsquosPercent of

Childrenrsquos $MedicaidTitle XIX(674 federal)

$760640800

$269079100

8868

SCHIPTitle XXI(77185 federal)

$15130000

$15130000

499

Federal Grants

$44631300

$10981200

362

County Funds (Maricopa Pima)

$39161500

$1803000

059

State Appropriations

$117516600

$6444600

212

Other

$3778200

0

000

Total Funding

$980858400

$303438500

10000

Behavioral Health Services in Arizona

Statewide enrollment 141393 (children and adults)Statewide children lt18 39020

ValueOptions enrollment 73845

ValueOptions children lt18 20041

Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm

13287

7270

20122

10530

19225

10217

27580

14316

28488

14725

34924

18892

34368

17199

39020

20041

05000

10000150002000025000300003500040000

2000 2002 2004 2006

Arizona T-19Maricopa T-19Arizona TotalMaricopa Total

Rapidly Expanding EnrollmentJune 2000 - June 2006

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 8: AZ CFTs Institute (Orlando, 2006)

Behavioral Health Services in Arizona

Statewide enrollment 141393 (children and adults)Statewide children lt18 39020

ValueOptions enrollment 73845

ValueOptions children lt18 20041

Source ADHS Enrollment and Penetration Report (May 2006) at httpwwwazdhsgovbhsenroll_penhtm

13287

7270

20122

10530

19225

10217

27580

14316

28488

14725

34924

18892

34368

17199

39020

20041

05000

10000150002000025000300003500040000

2000 2002 2004 2006

Arizona T-19Maricopa T-19Arizona TotalMaricopa Total

Rapidly Expanding EnrollmentJune 2000 - June 2006

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 9: AZ CFTs Institute (Orlando, 2006)

13287

7270

20122

10530

19225

10217

27580

14316

28488

14725

34924

18892

34368

17199

39020

20041

05000

10000150002000025000300003500040000

2000 2002 2004 2006

Arizona T-19Maricopa T-19Arizona TotalMaricopa Total

Rapidly Expanding EnrollmentJune 2000 - June 2006

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 10: AZ CFTs Institute (Orlando, 2006)

Impetus for Change

Community InitiativesLegislation ndash Executive OrderSystem of Care Grant ProgramLitigation

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 11: AZ CFTs Institute (Orlando, 2006)

Arizonarsquos Impetus JK Litigation

Governor ADHS

JK Settlement was groundbreaking First to overhaul a state mental health system that operated on a

managed care basis

httpwwwazdhsgovbhsjkfinalengpdf

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 12: AZ CFTs Institute (Orlando, 2006)

JK Settlement AgreementRequires ADHS and AHCCCS to

Invite and heed Family Voice Improve frontline practice Enhance capacity to deliver needed services

Promote collaboration among public agencies

Develop a quality management and improvement

system Termination of Agreement July 1 2007

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 13: AZ CFTs Institute (Orlando, 2006)

The Arizona VisionldquoIn collaboration with the child and family and others Arizona will provide accessible behavioral health servicesdesigned to aid children to

achieve success in school live with their families avoid delinquency become stable and productive adults

Services will be tailored to the child and family and provided in the most appropriate setting in a timely fashion and in accordance with best practices while respecting the childrsquos and familyrsquos cultural heritagerdquo

JK vs Eden et al No CIV 91-261 TUC JMR Paragraph 18

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 14: AZ CFTs Institute (Orlando, 2006)

The 12 Arizona Principles Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Familyrsquos Unique Cultural Heritage Independence Connection to Natural Supports

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 15: AZ CFTs Institute (Orlando, 2006)

Child and Family Team (CFT) Process

Based on the Wraparound ApproachService planning is family-centered strength-based highly individualized culturally competent and collaborative across systems promoting reliance on informal and natural supports in combination with formal services

Congruent with Family-Group Decision-Making (Child Welfare) Team Decision-Making (Child Welfare) Person-Centered Planning (Development Disabilities) Individual Family Service Planning (IDEA - Part C)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 16: AZ CFTs Institute (Orlando, 2006)

Child and Family Team ProcessThe Child and Family Team is a group of people that includes at a minimum the child the childrsquos family any foster parents a behavioral health representative and any individuals important in the childrsquos life who are identified and invited to participate by the child and family

Process for PracticebullCFT Formation Engagement

bullClinical Expertise Crisis Planning

bullService Authorization Consensus

bullStrength and Needs-Based Planning Single Points of Contact

bullPartnerships Cultural Competence

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 17: AZ CFTs Institute (Orlando, 2006)

How to Change Organizational Thinking

Attitudes and Values Language as an Organizing Framework Leadership ParentProfessional Partnerships Early Innovators

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 18: AZ CFTs Institute (Orlando, 2006)

Changing Organizational Thinking

Attitudes and Values The Relational Stance

From Problem to CompetenceFrom Expert to Accountable AllyFrom Professional Turf to Family TurfFrom Teaching to ldquoLearning Withrdquo

William C Madsen Collaborative Therapy with Multi-Stressed Families (1999)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 19: AZ CFTs Institute (Orlando, 2006)

Changing Organizational Thinking

Language as an Organizing Framework

ldquoLanguage creates a cultureLanguage preserves a culturerdquo

Bea Salazar Four Directions Consulting Riverton WY

Example Mental Retardation

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 20: AZ CFTs Institute (Orlando, 2006)

Changing Organizational Thinking

ParentProfessional Partnerships

Successful Business Practices Family is the Constant in Communities Voice Access and Ownership The Role of Power Collaboration at all Levels

State Local and Individual

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 21: AZ CFTs Institute (Orlando, 2006)

Changing Organizational Thinking

Philosophical Alignment of Child-Serving Systems

Behavioral Health as the CatalystChild Welfare Reform in ArizonaJuvenile Justice Transformation

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 22: AZ CFTs Institute (Orlando, 2006)

Partnerships

ldquoCollaboration An unnatural act between non-consenting adultsrdquo -- John VanDenBerg PhD

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 23: AZ CFTs Institute (Orlando, 2006)

Changing Organizational Thinking

Leadership

Sustainable TransformationGood Practice = Good BusinessDealing with ResistanceOvercoming Inertia

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 24: AZ CFTs Institute (Orlando, 2006)

Changing Organizational Thinking

Early Innovators

Urgency Ownership Commitment to Action Not for the Weak of Heart

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 25: AZ CFTs Institute (Orlando, 2006)

Arizonarsquos Early Innovators 300 Kids Project

ldquo49 Defendant ADHSDBHS shall initiate a 300 Kids Projectrdquo Will serve multi-agency children Sites to engage intensively in system improvement

activity

50 The sites will serve two purposes test strategies for providing behavioral health

services according to the 12 Principles Serve as the first phase of a statewide effort to

deliver services according to the Principles

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 26: AZ CFTs Institute (Orlando, 2006)

Going to Statewide Scale Practice Transformation

On January 29 2003 Gov Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide

implementation

1312003 ldquo300 Kidsrdquo (12 of 24110 total children)

1312005 58 with CFTs (n = 1895 of 32924)

5312006 3304 with CFTs (n = 11284 of 34368)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 27: AZ CFTs Institute (Orlando, 2006)

Structure Process Outcomes Structural Changes

Covered Services Funding

Process Changes Training and Coaching Consultants Professional Roles Clinical Guidance Documents

Outcomes Quality Management

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 28: AZ CFTs Institute (Orlando, 2006)

Structural Changes Necessary

Arizonarsquos Covered BH Services

Medicaid Behavioral Health Licensing Expanded Definition of ldquoprofessionalrdquo Expanded Definition of ldquofamilyrdquo Expansion of Supportive Services Capacity and Competency or

Quantity v Quality

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 29: AZ CFTs Institute (Orlando, 2006)

Structural Changes NecessaryArizonarsquos Covered BH Services

Prevention Services Rehabilitation Services Support Services Treatment Services Medical Services Behavioral Health Day Programs Crisis Intervention Services Inpatient Services Residential Services

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 30: AZ CFTs Institute (Orlando, 2006)

Covered BH Services in AZSupport ServicesCase ManagementPersonal Assistance Family Support Peer Support Therapeutic Foster Care Respite CareHousing Support Interpreter ServicesFlex Fund Services Transportation

Rehabilitation ServicesLiving Skills Training Cognitive Rehabilitation Health Promotion Supported Employment

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 31: AZ CFTs Institute (Orlando, 2006)

Structural Changes Necessary

Funding

Variations in State Capitation RatesMaximizing State FundingProvider Contracting MethodologySustainability of Effort

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 32: AZ CFTs Institute (Orlando, 2006)

Process Changes Necessary

Training and Coaching

Coaching to Support Training Sequencing Who Needs to Transform CostsInvestment RetentionRegeneration Strategies

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 33: AZ CFTs Institute (Orlando, 2006)

Process Changes Necessary

Consultants

State and Local StrategiesChoosing a ConsultantCoordination of Effort Individual vs Systemic

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 34: AZ CFTs Institute (Orlando, 2006)

Process Changes Necessary

Professional Roles

Transforming Roles ndash Relational Stance Movement to Strengths Based Values-Based Hiring Practices Training and Re-training Liability Myths Shared Expertise with Families

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 35: AZ CFTs Institute (Orlando, 2006)

Process Changes Necessary

Clinical Guidance Documents

Operationalizing and Memorializing Process for Development Contract Requirements Standardized Assessment (0-5 too) Example Child and Family Team PIP Prior Authorization

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 36: AZ CFTs Institute (Orlando, 2006)

Process Changes Necessary

Quality Management Systems

ldquoStructure Process OutcomesrdquoQuality vs QuantityMedicaid Requirements vs

System of Care Values Cost and Resources

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 37: AZ CFTs Institute (Orlando, 2006)

Quality Management Structure

Examples EnrollmentPenetration (Latino youth 0-3 yo) Number of functioning Child and Family Teams Number of counties with cross-system protocols

agreements in place Number of children placed outside of Arizona Number of children placed out of home Percentage of children in foster care with BH needs

assessed beginning within 24 hours after removal

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 38: AZ CFTs Institute (Orlando, 2006)

Quality Management Structure

JK ldquoStructural Elementsrdquo (monthly) - CFT Capacity OOH Placements Urgent BH Responses

ValueOptions Key Indicators (monthly) - CFT Capacity by Provider RehabSupport Spending as of Total BH $ Latino Penetration by Provider ldquoUnder 12rdquo Initiative

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 39: AZ CFTs Institute (Orlando, 2006)

Quality Management Structure

Maricopa CountyTFC Placements - increased from 5 (0903) to 196 (0506) ndash now 50 of all children OOH

Children Placed Out of State ndash Decreased from 57 (0602) to 8 (0306)

ArizonaTFC Placements ndash increase from 9 (0903) to 404 (0506) ndash now 41 of all children OOH

Children Placed Out of State ndash Decreased from 100 (0602) to 25 (0306)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 40: AZ CFTs Institute (Orlando, 2006)

Quality Management Process

CFT Process Measurement [Maricopa Co]ldquoThe Four Big Questionsrdquo

1 Has a trusting relationship been established with the family (engagement)

2 Does the Child and Family know the family and has it identified the strengths needs and culture of the family

3 Has an Individualized Service Plan been created that meets the needs of the child and family

4 Is the team implementing monitoring and modifying the service plan toward a successful outcome for the child and family

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 41: AZ CFTs Institute (Orlando, 2006)

Quality Management ProcessCFT Process Measurement

Fall 2005 ReviewsRegion A ndash 678Region B ndash 641Region C ndash 741Region D ndash 663Region E ndash 733Region F ndash 417

Statewide 5325 [n = 486]

Winter 2006 ReviewsRegion A ndash 70Region B ndash 64Region C ndash 71Region D ndash 61Region E ndash 81Region F ndash 53

Statewide 6045 [n = 418]

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 42: AZ CFTs Institute (Orlando, 2006)

Improved Processes Improved Outcomes

EXAMPLEs

Wraparound Milwaukee Residential placements decreased by 60 Psychiatric hospitalization decreased by 80 Reduced recidivism by delinquent youth Overall cost of care per child decreased

Bruce Kamradt Child Welfare League of America 2001 National Conferenceand Report of the Surgeon General on Childrenrsquos Mental Health (1999)

Project MATCH (Pima County AZ)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 43: AZ CFTs Institute (Orlando, 2006)

Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)

High Fidelity CFT Low Fidelity CFTWFI Scores 853 536

CAFAS 132 128

CBCL Total 89 78

Level of Residential Placement

17 17

Number of Moves in Previous Six Months

22 16

Family Resource Scale 35 31

ldquoIt Even Works in Arizonahelliprdquo

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 44: AZ CFTs Institute (Orlando, 2006)

8090

100110120130140150160

Intak

e

6 Month

s

12 M

onths

Time Interval

Ave

rage

CA

FAS

Scor

e

Overall HF CFT LF CFT

5060708090

100

Intake

6 Months

12 M

onths

Time IntervalA

vera

ge C

BC

L To

tal S

core

Overall LF CFTHF CFT

Figure Two CAFAS and CBCL Scores The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake The open circles are the average scores for all 42 children the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores From Rast OrsquoDay amp Rider (2004)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 45: AZ CFTs Institute (Orlando, 2006)

10152025303540

Time Period

Ave

rage

Res

iden

tial L

evel

Overall Low FidelityHigh Fidelity

0005

1015

2025

Intake

6 Month

s

12 M

onths

Ave

rage

Mov

es p

er S

ix M

onth

s

Overall Low FidelityHigh Fidelity

Figure Three Residential Outcomes Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph) The figure on the left shows the average level of residential placement on a six level version of the ROLES The open circles show the average for all 42 of the children the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound The graph on the right shows the average number of residential moves for each group using the same symbols From Rast OrsquoDay amp Rider (2004)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 46: AZ CFTs Institute (Orlando, 2006)

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S Sc

ore

Overall

2022242628303234363840

Intake

6 Month

s

12 M

onths

Ave

rage

FR

S S

core

Low Fidelity High Fidelity

Figure Four Family Resource Scale Figure Four shows the scores for the Family Resource Scale which measures a caregiverrsquos report on the adequacy of a variety of resources needed to meet the needs of the family as a whole as well as the needs of individual family members Higher ratings demonstrate more adequate resources The graph on the left shows the average rating for the caregivers for all 42 children The graph on the right shows the average rating for each group The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound From Rast OrsquoDay amp Rider (2004)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 47: AZ CFTs Institute (Orlando, 2006)

Promising Data about Arizona Children

Success in School ndash Past Six Months Age 5-11 112 higher with CFT (642) Age 12-17 126 higher with CFT (651)

Lives with Family ndash Past Six Months Age 5-11 67 higher with CFT (870) Age 12-17 47 higher with CFT (755)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 48: AZ CFTs Institute (Orlando, 2006)

Promising Data about Arizona Children

(Increased) Stability ndash Past Six Months Ages 5-11 145 higher with CFT (740) Ages 12-17 169 higher with CFT (704)

(Increased) Safety ndash Past Six Months Ages 5-11 109 higher with CFT (692) Ages 12-17 114 higher with CFT (662)

ADHS CIS (0506) N = 31690 childrenfamilies

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 49: AZ CFTs Institute (Orlando, 2006)

Promising Data aboutArizonarsquos Children

Avoids Delinquency ndash Past Six Months Age 5-11 92 higher with CFT (725) Age 12-17 110 higher with CFT (697)

Preparation for Adulthood ndash Past Six Months Age 5-11 63 higher with CFT (574) Age 12-17 101 higher with CFT (574)

ADHS CIS (0506) N = 31690 childrenfamilies

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 50: AZ CFTs Institute (Orlando, 2006)

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled children in this age range

00100200300400500600700800900

CFTNo CFT

CFT 751 711 760 583 667 877

No CFT 596 593 658 524 545 817

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 51: AZ CFTs Institute (Orlando, 2006)

Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf

for all enrolled youth in this age range

00

200

400

600

800

1000

CFTNo CFT

CFT 712 685 713 565 648 811

No CFT 550 571 608 481 539 774

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 52: AZ CFTs Institute (Orlando, 2006)

Family Perceptions of Outcomes

Practice Based Evidence

Practical approach Strength based Positive risk taking Gives voice to both families being

served and to frontline workers

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 53: AZ CFTs Institute (Orlando, 2006)

Next Steps in Arizona

Building Capacity and Competency

Children 0-3 yo and Their FamiliesSubstance AbusePositive Behavior SupportChild Welfare (See Institute 24)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 54: AZ CFTs Institute (Orlando, 2006)

Next Steps in ArizonaNatural SupportsYouth VoiceAdult System Transformation

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions
Page 55: AZ CFTs Institute (Orlando, 2006)

Questions

Thank you for your attention

Toni Robin Frank and Dr Ray

  • Individualizing Care Within a Managed Care Context
  • Institute 4 Overview
  • Change vs Transformation
  • Why is Transformation Necessary
  • Slide 5
  • Arizonarsquos Behavioral Health System
  • Arizona BH Funding for Children
  • Behavioral Health Services in Arizona
  • Slide 9
  • Impetus for Change
  • Arizonarsquos Impetus JK Litigation
  • JK Settlement Agreement
  • The Arizona Vision
  • The 12 Arizona Principles
  • Child and Family Team (CFT) Process
  • How to Change Organizational Thinking
  • Changing Organizational Thinking
  • Slide 19
  • Slide 20
  • Slide 21
  • Partnerships
  • Slide 23
  • Slide 24
  • Arizonarsquos Early Innovators 300 Kids Project
  • Going to Statewide Scale Practice Transformation
  • Structure Process Outcomes
  • Structural Changes Necessary
  • Slide 29
  • Covered BH Services in AZ
  • Slide 31
  • Process Changes Necessary
  • Slide 33
  • Slide 34
  • Slide 35
  • Slide 36
  • Quality Management Structure
  • Slide 38
  • Slide 39
  • Quality Management Process
  • Quality Management Process CFT Process Measurement
  • Improved Processes Improved Outcomes
  • Figure One Group Comparisons Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake The second row shows the difference in the overall average WFI scores for the two groups The WFI eight point scale has been converted to a 100 point scale for ease of comparison Rows three through seven show the intake data for four of the primary child and one primary family outcomes These data reflect the six months prior to initiation of the wraparound process From Rast OrsquoDay amp Rider (2004)
  • Slide 44
  • Slide 45
  • Slide 46
  • Promising Data about Arizona Children
  • Slide 48
  • Promising Data about Arizonarsquos Children
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 5-11 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled children in this age range
  • Comparing Outcomes for Arizona Children with and without Child and Family Teams Ages 12-17 From ADHS (9606) at httpwwwazdhsgovbhsmeasurescharts_0806pdf for all enrolled youth in this age range
  • Family Perceptions of Outcomes
  • Next Steps in Arizona
  • Slide 54
  • Questions

Related Documents
Correspondences between WZNW models and CFTs with W ...creutzig/articles/JHEP_WZWtoToda3.pdfPrepared for submission to JHEP RUP-15-19 Correspondences between WZNW models and CFTs with

Correspondences between WZNW models and CFTs with W...

Category: Documents
CFTS Model

CFTS Model

Category: Documents
Landau-GinzburgOrbifolds and Symmetriesof K3 CFTs · Landau-GinzburgOrbifolds and Symmetriesof K3 CFTs ... K3 symmetries, ... be realized as a symmetry of some K3 sigma model. This

Landau-GinzburgOrbifolds and Symmetriesof K3 CFTs ·...

Category: Documents
D. Klemm et al- Universality and a generalized C-function in CFTs with AdS Duals

D. Klemm et al- Universality and a generalized C-function in...

Category: Documents
Overview of Quaternion and Clifford Fourier Transformations · 2015-04-02 · Cliff. Alg. + Calc. CFT overview Two-sided CFTs One-sided CFTs Conclusion + Refs. Overview of Quaternion

Overview of Quaternion and Clifford Fourier...

Category: Documents
NMSDC 2020 SAVE THESE DATES€¦ · Phoenix, AZ • • Program Managers’ Seminars July 14-16 Orlando, FL Network Leadership Meeting July 15-17 Orlando, FL Workshops, Meetings and

NMSDC 2020 SAVE THESE DATES€¦ · Phoenix, AZ • •...

Category: Documents
2016 AVCA Phenom List · Alexandria Johnson 6'3 MB 2018 Notre Dame Preparatory High School AZ East Valley Juniors AZ ... Giao Huynh 6'1 MB/RS 2018 West Shore Senior High School Orlando/Tampa

2016 AVCA Phenom List · Alexandria Johnson 6'3 MB 2018...

Category: Documents
Zig - wehelpschools.comwehelpschools.com/ezine/az/docs/2015/2015_AZ_Proud_History.pdfHigley Unified SD (Orlando) 2012 Cindy Riley, CAA Desert Christian HS (San Antonio) **Since Deceased

Zig -...

Category: Documents
Bootstrapping MN and Tetragonal CFTs in Three Dimensions ... · Bootstrapping MN and Tetragonal CFTs in Three Dimensions Andreas Stergiou Theoretical Division, MS B285, Los Alamos

Bootstrapping MN and Tetragonal CFTs in Three Dimensions...

Category: Documents
About CFTs · Web viewAWS CloudFormation Templates (CFTs), are JSON files that can launch nearly all AWS resources including VPCs, subnets, security groups, route tables, plus many

About CFTs · Web viewAWS CloudFormation Templates (CFTs),.....

Category: Documents
Standoffs For Thin Sheet Material Series CFT, CFTS, CFTA

Standoffs For Thin Sheet Material Series CFT, CFTS, CFTA

Category: Documents
2011 Kia Rio Orlando | Orlando Kia

2011 Kia Rio Orlando | Orlando Kia

Category: Business