powerpoint presentation the systems of care philosophy & values ... goals, & communication...

7/23/2014

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© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY

Evidenced-based Practices: Strategies for Taking

Evidence-based Practices to Scale within States'

Systems of Care for Children's Mental Health

The TA Center EIP Committee My Banh, Ph.D.

Alfiee M. Breland-Noble, Ph.D. MHSc. © 2014 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY

• Funding for this training was made possible in part by Grant Number 5UR1SM059944-03 from SAMHSA. The views expressed in written materials or publications and by trainers and facilitators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government

The TA Center EIP Committee:

Acknowledgments

Bruno Anthony, Ph.D.

[email protected]

My Banh, Ph.D.

[email protected]

Alfiee Breland-Noble, Ph.D., MHSc.

[email protected]

Sybil Goldman, M.S.W

[email protected]

Vivian Jackson, Ph.D.

[email protected]

Nicole Kahn, M.A.

[email protected]

Teresa King, B.A.

[email protected]

Sherry Peters, M.S.W., A.C.S.W.

[email protected]

Jim Wotring, M.S.W.

[email protected]


• Presentations

• Scaling up Evidence-Based Practices (EBPs) within Systems of Care (SOC)

– Introduce Integrative Service Systems Approach (ISSA) for scaling up EBPs

– “Real world’ examples from states

• Break

• Cultural Relevance of Evidence Based Practices for Children’s Mental Health

– Important points to consider in scaling up

– Description and role of cultural adaptations of EBPs

• Break

• Small group exercise – Apply model to your real world experience

• Team will provide guidelines for group discussion

• Discussion & Closing – Feasibility of implementing ISSA in real-life settings

Session Agenda

3 © 2014 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY

• Review the Systems of Care philosophy & values

• Describe factors that facilitate scaling up of EBPs within a Systems of Care framework

• Gain practical tenets for cultural adaptations and application of EBPs

• Assess feasibility of scaling up EBPs from a Systems of Care framework

Learning Objectives

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• Include an array of accepted treatment approaches with some degree of evidence for effecting positive mental health outcomes in racially and ethnically diverse children. The range of approaches to consider includes (in no particular order): – Practice-based evidence (PBE) for racially/culturally diverse

groups

– Evidence Based Treatments (EBTs)-Manualized

– Culturally adapted EBTs

–Managing and Adapting Practice (MAP) (Bruce Chorpita)

– Behavioral and Affective Skills for Coping (BASIC) Approach (John Weisz)

Broad Definition of Evidence-based Practices (EBPs)


A system of care is:

• a spectrum of effective community-based services and supports for children and youth with or at risk of mental health challenges and their families

• is organized into a coordinated network

• builds meaningful partnerships

• addresses youth and families cultural and linguistic needs to help them function better.

Stroul, Blau, & Friedman (2010)

Systems of Care: Definition

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Systems of care are a range of treatment services and supports guided by a philosophy and supported by an infrastructure.

Systems of Care

Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional

disturbances (Rev. ed.) Washington, DC: Georgetown University Child Development Center, National

Technical Assistance Center for Children’s Mental Health. Reprinted by permission.


Philosophy and values:

• family-driven

• youth-guided

• culturally and linguistically competent

• individualized based on strengths

• community-based

• comprehensive and coordinated cross-system

Systems of Care Philosophy & Values


Infrastructure

• Policies and regulations

• Cross-system governance structures (e.g. mental health, substance abuse, health, child welfare, juvenile justice, education, early childhood)

• Financing strategies including incentives

• Strategies for developing and expanding services and supports that are individualized, coordinated, integrated, and evidence-based

• Workforce development, training, and technical assistance

• Quality assurance and the monitoring of outcomes

• Social marketing and strategic communications

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Infrastructure incorporates structures, processes, and

capacity building at state and community levels:


• Maximize impact of SOC and EBPs

• Provide infrastructure for implementing EBPS – Financing, access to care, assessment & monitoring

outcomes

– Strategies for implementation

• Build on the collaborative processes and increase coordinated care across systems

• Increase availability of efficacious mental health treatments Improve mental health outcomes

• Enable families and youth to have more choices for efficacious services

Benefits of Integrating SOC & EBPs


Child, Youth & Family

Systems of care philosophy & values

Child, Youth, & Families Strategies:

• Family-driven & choice

• Youth-guided

• Individualized

• Culturally/linguistically competent

• Coordinated & effective

• Home & community-based


Integrated Service Systems Approach (ISSA)


State Systems: Infrastructure

Agency / Organization: Implementation Plan

Services & Providers:

Effective delivery of treatments

Child, Youth & Family: Family Voice & Choice

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State Systems: Creating Infrastructure Systems of care philosophy & values

Common State Systems Elements/Strategies:

• Cross-agency coordination & leadership:

• Core group to lead Interagency Team

• Clear vision, goals, & communication plan

• Data infrastructure for data management:

• Screening/assessment/outcomes

• System wide CQI/performance measurement

systems

• Relevance mapping for EBP selection

• State Center of Excellence

• Financial structures to bill for EBP services

• Waiver programs & case rate financing

• Fiscal incentives for EBPs & CQI

• Higher education certification/ credentialing for EBPs

• Family/youth advocacy for EBPs


Agency/Organization: Implementation Plan & Supports


Common Agencies/Organizations Strategies:

• Leadership climate & culture

• Collaborations & buy-in at all levels

• Implementation plan & supports

• Integrated data systems

• Staff selection and retention

• Workforce & business training for retention &

sustainability

• Supervision/consultation/feedback

• Incentives for EBP use

• Subsidies for training & monitoring

• Adapt & test promising interventions


Services & Providers: Effective Delivery of Services


Common Services/Providers Strategies:

• On-going assessment & treatment planning

• Provision of an array of services with fidelity:

• Manualized EBPs

• Common elements: MAP

• Common factors:

• family engagement/alliance

• cultural/linguistic competence

• family/youth support

• Care Coordination/Wraparound




Common Child, Youth, & Families Strategies:

• Informing families about EBPS & focus on positive

outcomes

• Family-driven & choice

• Youth-guided

• Individualized

• Culturally/linguistically competent

• Coordinated & effective

• Home & community-based






Services & Providers:

Effective delivery of treatments



• Implemented CASSP

• Implemented Wraparound, Intensive In-home Services, and Respite statewide

• Implemented a Level of Functioning Project (LOF) using the CAFAS: Data

• Implemented evidence based practices

Implementation plan: Waves of

Change

The Michigan SOC-EBP Experience

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Strategies SOC-CASSP Evidence Based

Practices Strong Leadership Support from the

Directors

Support from the

Directors

Created a Sense of

Urgency : Develop clear

vision

Out of Home Care

Community Based Care

Effective Services

Relevance mapping of

EBPs

Wrap-around CBT and PMTO

MI Scaling-up Implementation Strategies

Adapted from Kotter, J.P. The Heart of Change (2002). © 2014 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY

0%

10%

20%

30%

40%

50%

60%

% N

ot

Im

pro

vin

g

Home School Behavior

Toward

Others

Moods Community Substance

Use

Thinking Self-Harm

CAFAS Subscales

Percentage of Youth Not Improving on

each CAFAS Subscale: The Impetus


Which EBPs Could Help the Most Youths?

Mild Mood/Behavior Thinking

Substance Use

Self-Harm

Delinquency Behavior with Mood

Behavior

Parent Management

Training

(PMT)

Cognitive Behavior

Therapy for

Depression (CBT)

Wrap-around

Services


Strategies SOC-CASSP Evidence Based Practices

Cross-agency

coordination: Broad

Participatory Planning

Steering Committee-

Strategic Plan for

Visioning

Steering Committee-Logic Model

For Visioning

Core Team to Guide

Implementation

Core Group to Lead-

Interagency Team

Core Group to Lead-Purveyors, State

and Local Staff

Supported Others to

Lead

State and Local Wrap

Teams

State and Local PMTO Teams

Communication Plan Part of Participatory

Planning and

Visioning, Travel

Throughout the State

Part of Participatory Planning and

Visioning , Travel Throughout the

State

Strong Leadership Support from the

Directors

Support from the Directors

MI Core Implementation Strategies

Adapted from Kotter, J.P. The Heart of Change (2002).


Youth & Families

Representatives from all Child-

Serving Systems

Advocates Service Providers

Attention to Geographic and

Cultural Diversity

Steering Committee & Core Teams


Strategies SOC-CASSP Evidence Based

Practices

Data system: Celebrate

short-term wins

Used Evaluation Data Used CAFAS Data

Finance Plan Developed extensive

plan

Used plan for EBP’s

Waves of Change –State

Center of Excellence

Wrap-around, Intensive

In-Home, Respite

Expanded PMTO

statewide, Coaches,

Fidelity Monitors

MI Scaling-up Implementation Strategies

Adapted from Kotter, J.P. The Heart of Change (2002).

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Lead, Lead, Lead

Create sense of Urgency

Regular communication & coordination between and within all levels

Develop and strengthen infrastructure

Develop a finance plan from multiple sources

Develop data monitoring system

Execute and embed policies and practices at multiple levels

Core Strategies that Enhanced SOC + EBP Integration & Scaling up


• Greater emphasis on children and families in the Office of Mental Health

• Statewide CASSP Coordinator

• Children’s Mental Health Specialists in each regional office

• CASSP Coordinators in each county mental health program

• Statewide CASSP Advisory Committee

1985 Federal CASSP grant :

The Pennsylvania SOC & EBPs Experience


Families and Advocates (over 50%

of members)

Representatives from all Child-

Serving Systems

County CASSP Coordinators

Service Providers

Attention to Geographic and

Cultural Diversity

CASSP Advisory Committee


Early 1990’s Settlement Agreement required

development of broad service array of home and community

based services

• Huge increases in spending over a decade of service development

• Little evidence that services were effective

• All stakeholders recognized need to find alternative services that would be effective

Intervening 10 Year Long Catalyst Leading to Beginning of EBPs


Establishing child and family teams and implementing

High-Fidelity Wraparound as a practice model

Developing a process for

identifying and implementing

evidence-based and promising

practices as well as culturally

relevant practices.

2005 - Advisory Committee Set Goal of Transforming the Children’s Behavioral Health

System to Include:


Multi-Systemic Therapy (MST)

Functional Family Therapy (FFT)

Multi-Dimensional Treatment Foster Care (MTFC)

Parent Child Interaction Therapy (PCIT)

Trauma-Focused Cognitive Behavior Therapy (TF-CBT)

Sanctuary in both Residential and Community Based Settings

Positive Behavioral Interventions and Supports (PBIS) in Schools

Existing Infrastructure for SOC Influenced Selection of EBPs

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Obtaining Buy-In Through Regular

Communication 1992 to present

• Alert, a monthly administrative update

• The PA CASSP Newsletter, a quarterly publication on children’s behavioral health.

Capacity Building Strategy Led by Office of Mental Health


Cross-System: all the child-serving systems and stakeholders

Cross-Levels: Federal/State/Local

Cross-Branches: Executive, Legislative, Judicial

Cross-Function: Government and Providers of Services

Importance of Collaborative Relationships to Build Capacity


State Child-Serving Systems

County Child-Serving Systems

Behavioral Health Managed Care Organizations

Service Providers

Shared Responsibility for Building Statewide Capacity for EBPs


Federal funding to strengthen infrastructure

Strong relationships at all levels

Regular communication between and within all levels

Shared vision and goals

Shared responsibility for funding and workforce development

Core Strategies that Enhanced SOC + EBP Integration


Lead, Lead, Lead: Continuity of leadership

Create sense of Urgency: Create shared vision & goals

Develop strong partnerships: Regular communication & coordination between and within all levels

Develop and strengthen infrastructure

Develop a finance plan from multiple sources

Develop data monitoring system

Execute and embed policies and practices at multiple levels

Core Strategies that Enhanced SOC + EBP Integration & Scaling up



Services & Providers: Coordinated & Effective care





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The Import of Culturally Relevant Care


Cultural Relevance of EBPs

• ”If there are systematic differences in the

empirical connection between symptoms and

disorders by race, ethnicity, or other factors, then

failing to take these into account will result in

more diagnostic and treatment referral errors

for… populations [of people of color],

contributing to disparities in services and in

outcomes….” pp.257-258

Alegria, M., & McGuire, T. (2003). Rethinking a universal framework in the

psychiatric symptom-disorder relationship. Journal of Health and Social

Behavior, 44(3), 257-274.

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• have a defined set of values and principles, and demonstrate

behaviors, attitudes, policies and structures that enable them to work effectively cross-culturally.

• have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge and (5) adapt to diversity and the cultural contexts of the communities they serve.

• incorporate the above in all aspects of policy making, administration, practice, service delivery and involve systematically consumers, key stakeholders and communities.

• Cultural competence is a developmental process that evolves over an extended period. Both individuals and organizations are at various levels of awareness, knowledge and skills along the cultural competence continuum. (adapted from Cross et al., 1989)

Cultural competence requires that organizations:


The capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who have low literacy skills or are not literate, individuals with disabilities, and those who are deaf or hard of hearing.

Cultural Competence (con’t)


Requires organizational and provider capacity to respond effectively to the health and mental health literacy needs of populations served. The organization must have policy, structures, practices, procedures, and dedicated resources to support this capacity.

Linguistic Competence


What are some examples of how your organization ensures Cultural and Linguistic Competence?

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Examples

• Cultural Competence Hire Racially and Ethnically diverse staff

and providers

Recruit, promote, and support a diverse governance, leadership, and workforce

Collect and maintain demographic data

Conduct assessments of community health assets and needs

Partner with the community

Create conflict and grievance resolution processes

• Linguistic Competence bilingual/bicultural or

multilingual/multicultural staff;

cultural brokers

foreign language interpretation services including distance technologies

sign language interpretation services

multilingual telecommunication systems

videoconferencing and telehealth technologies

TTY and other assistive technology devices

print materials in easy to read, low literacy, picture and symbol formats


According to one of the leaders in the field, Dr. Guillermo Bernal of the University of Puerto Rico…

“The systematic modification of an EBT or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values.”pp.361-362

Bernal, G., Jimenez-Chafey, M. I., & Rodriguez, M. M. D. (2009). Cultural Adaptation of Treatments: A Resource for Considering Culture in Evidence-Based Practice. [Article]. Professional Psychology-Research and Practice, 40(4), 361-368.

What is Cultural Adaptation


• Why is this important? – Engagement

– Relevance

– Retention

– Cultural Competence

–Outcomes

Key Points to Consider

• Does it Work?

• Many would argue, yes – Benish, S. G., Quintana, S., & Wampold, B.

E. (2011). Culturally Adapted Psychotherapy and the Legitimacy of Myth: A Direct-Comparison Meta-Analysis. [Article]. Journal of Counseling Psychology, 58(3), 279-289.


• Does it Work?

• Many would argue, yes – Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally Adapted

Psychotherapy and the Legitimacy of Myth: A Direct-Comparison Meta-Analysis. [Article]. Journal of Counseling Psychology, 58(3), 279-289.

• “culturally adapted psychotherapy is more effective than unadapted, bona fide psychotherapy by d = 0.32 for primary measures of psychological functioning.”

• From Abstract

– Griner, D., & Smith, T. B. (2006). Culturally adapted mental health interventions: A meta-analytic review. [Review]. Psychotherapy, 43(4), 531-548. • “Across 76 studies the resulting random effects weighted average ;effect size was d = .45, indicating a moderately strong

benefit of culturally adapted interventions. Interventions targeted to a specific cultural group were four times more effective than interventions provided to groups consisting of clients from a variety of cultural backgrounds.”

• From Abstract

Key Points to Consider


• Involve the population of interest – Patients AND Providers are your experts

• Plan your work

• Work your plan

• Review the literature

• Pilot test your adaptations

• Evaluate & make changes and retest

HOW? To Adapt


Adaptation Points to Remember

• Examine outcomes

– Patient Level

• Do the children improve?

– Provider Level

• Are your provider comfortable?

• Do they implement using principles taught?

– Policy Level

• Can you pitch utility of adaptation to stakeholders?

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Group Exercise

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• Within the SOC philosophy of family-driven, youth-guided, individualized, culturally/linguistically competent, coordinated & effective , home & community-based: you have been tasked with scaling up an EBP in your state. At minimum, you need to: • 1) address how this EBP will fit within the diverse

communities that you serve and

• 2) identify key components that will be needed to create a data system to monitor outcomes

• Time permitting, how would you go about developing the workforce to scale-up the EBP?


• Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st Century. Washington, DC: Author.

• Knitzer, J. (1982). Unclaimed children: The failure of public responsibility to children and adolescents in need of mental health services. Washington, DC: Children's Defense Fund.

• Kotter, J.P. The Heart of Change (2002). Boston, MA: Harvard Business School Publishing. • Meyers, D.C., Durlak, J.A., Wandersman, A. (2012). The Quality Implementation Framework: A Synthesis of Critical Steps in

the Implementation Process. Am J Com Psych, 50, 3-4, pp 462- 480. • President’s New Freedom Commission on Mental Health. (2003). Subcommittee on Children and Families Summary Report. Retrieved March 2005 from http://govinfo.library.unt.edu/mentalhealthcommission/subcommittee/Sub_Chairs.htm

• Stroul, B, Blau, G., & Friedman, R. (2010). Updating the system of care concept and philosophy. Washington, DC: Georgetown University Center for Child and Human Development National Technical Assistance Center for Children’s Mental Health, from: http://www.tapartnership.org/docs/UpdatingTheSOCConcept2010.pdf

• Stroul, B & Blau, G. (2008). The system of care handbook: Transforming mental health services for children, youth, and families. Baltimore, MD: Paul H. Brookes Publishing Co.

• Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (Rev. ed.) Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Children’s Mental Health. Reprinted by permission.

• Stroul, B., Goldman, S., Pires, S., & Manteuffel, B. (2012). Expanding systems of care: Improving the lives of children, youth, and families. Washington, DC: Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health.

• U.S. Public Health Service, U.S. Department of Health and Human Services, Office of the Surgeon General. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/

References


Service and Supports

Services and supports-- that incorporate EBPS:

• prevention

• early intervention

• assessment

• wrap-around approaches

• outpatient modalities

• home-based services

• crisis intervention

• respite care

• behavioral aides

• care management

• range of residential and inpatient options


• IOM called for “creating an infrastructure to support evidence-based practice.”

• Both public and private funding mechanisms to facilitate EBP dissemination and implementation emerged.

• Government agencies began to create financial, regulatory incentives, and mandates for implementation of evidence-based practice.

Creating a sense of urgency for EBPs


• Cognitive Behavior Therapy for Depression

• Parent Management Training – Oregon Model

• Trauma Focused Cognitive Behavioral Therapy

• Multi-systemic Therapy

• Functional Family Therapy

• System of Care for Children w/SED and their Families

• Wraparound Model

• Positive Behavioral Interventions and Supports (PBIS) in Schools

Evidence Based Treatments

Evidence-informed practices

Relevance Mapping of EBPs


Obtaining Buy-In Through Publications

Child, Family and Community Core Competencies, originally

published by the former PA CASSP Training and Technical Assistance

Institute, 1999.

Guidelines for Best Practice in Children’s Mental Health Services, by Gordon R. Hodas, M.D., Office of Mental Health and Substance

Abuse Services, 2001.

Capacity-Building Strategy Led by Professionals

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• “Pennsylvania Model of ‘Towards a Culturally Competent System of Care’” - 1990's (based on the Federal CASSP monograph, “Towards a Culturally Competent System of Care.”)

• Performance Expectations and Recommended Guidelines for County CASSP Systems 2002

Obtaining Buy-In Through

Collaboratively Developed Guidelines

Capacity Building Strategy Led by CASSP Advisory Committee

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