Advances in Systems of Care and the Wraparound ProcessJohn VanDenBerg, Ph.D.Vroon VanDenBerg LLP

Systems of Care Co-morbidity and Co-occurring disorders Our youth and families do not fit our neat

agency boundaries and funding silos Systems of Care evolved in the 1980’s in

recognition of the need to better support child with complex emotional needs and their families

Lessons about Systems of Care Initially, we were naïve about what it would

take to do this. Early research (Bickman and others) showed

that clinical outcomes were not significantly improved in “System of Care” communities

Collaboration without Integration does not produce outcomes

Collaboration and Integration DefinitionsCollaboration: Agencies are familiar with each other’s missions

and roles, key staff work with each other at the child/family level, but often retain single system decision making power and planning.

Integration: Agencies are familiar with each other’s missions and roles, key staff work with each other at the child/family level, sharing decision making in a team format that includes the family in the drivers seat, producing a single plan that meets all system mandates and that is owned by the entire team.

A Quick Poll…. Thinking of your area of Washington state,

rate the overall degree of collaboration from 1 to 10, with 10 being the highest possible, most positive level.

Now, do the same for integration. Get ready to raise your hand when I get to

your number as I count from 1 to 10… Why the difference?

Public Policy Implications: Lack of Integration Almost all children and youth consuming

over $15,000 worth of public funding per family have co-occurring disorders, especially when one considers several generations of the family.

Nationally, little true integration of policy and planning exists for these youth.

The source of our system’s greatest potential is in the area of integration

Research Lessons from Systems of Care Collaboration without practice change is

meaningless Within-systems innovation is often negated

by the fact that the innovation does not go across silos.

For Example…. A local child welfare office is using Family Group Decision

Making to support a family to develop their own safety plan, an accepted best practice within child welfare.

If a child in the family is also on probation, or is in special education and struggling with learning, frequently those issues and those agencies are not present during the FGDM planning

The big picture of success for this family involves success with juvenile justice, school, as well as safety issues, and yet no process is in place to ensure cross-system planning

Remember one thing… High Fidelity Wraparound is a process of

integration Systems of Care has to involve practice

change, and Wraparound is a significant practice change for most systems

High Fidelity Wraparound Wraparound is a facilitated team based practice

model designed to integrate natural and professional supports, with the family in the driver’s seat

A wraparound team is formed to help define and refine family strengths, culture, vision and needs; prioritize needs and create the plan; and then carry out the plan one prioritized need at a time until the formal team is no longer needed because the vision of the family has been achieved.

Principles for Wraparound Family Voice and

Choice Team Based Natural Supports Collaboration (and

Integration) Community Based Culturally

Competent

Individualized Strengths Based Unconditional Care Outcome Based and

Cost Responsible

Universal Principles? Nursing homes: The Eden Principles Prison Wraparound to reduce recidivism Balanced and Restorative Justice: Juvenile Justice Family Group Decision Making: Child Welfare Positive Behavioral Supports: Schools Individualized Addiction Interventions Brief Stabilization Residential Services The Recovery Movement: Adult Mental Health

Efficacy

Why Does Wraparound Work?

Integrated Plan

NaturalSupportSystem

Self

Efficacy

FamilyPrioritized

Needs

Wraparound addresses the priority needs identified by

the youth and family

Efficacy

Integrated Plan

NaturalSupportSystem

Self

Efficacy

FamilyPrioritized

Needs

Wraparound strengthens youth and families

confidence that they can create positive change

in their lives

Efficacy

Integrated Plan

NaturalSupportSystem

Self

Efficacy

FamilyPrioritized

Needs

Wraparound strengthens the social support system that

helps the youth and family succeed

Efficacy

Integrated Plan

NaturalSupportSystem

Self

Efficacy

FamilyPrioritized

Needs

Wraparound creates an

integrated and simplified plan for the whole

family

Efficacy

Integrated Plan

NaturalSupportSystem

Self

Efficacy

FamilyPrioritized

Needs

Wraparound is not in conflict with other methods of individualization

For example, Family Group Decision Making, which is primarily focused on child safety –

FGDM can use wrap process to pick up if safety and other family issues will need ongoing support

Wraparound often uses FGDM as transition planning for wrap

A FGDM team can combine with wrap team to deal with many family and adult needs as well as safety

Growth of Wraparound In January of 2007, a Google search of the

term “Wraparound Families” found about 300,000 “hits”

In August of 2010, a Google search of the term “Wraparound Process” found almost 1,000,000 “hits”

Positive Outcomes are Not Guaranteed!

Studies indicate that Wraparound teams often fail to: Incorporate full complement of key individuals on the

Wraparound team; Use family/community strengths to plan/implement services; Engage natural supports, such as extended family members

and community members; Use flexible funds to help implement strategies Consistently assess outcomes and satisfaction.

(Dr. Eric Bruns, Evidence Based Practices Institute, UW)

What is the connection between fidelity and outcomes with wraparound?

Provider staff whose families experience better outcomes were found to score higher on fidelity tools (Bruns, Rast et al., 2006)

Wraparound initiatives with positive fidelity assessments demonstrate more positive outcomes (Bruns, Leverentz-Brady, & Suter, 2008)

What does it take to get high fidelity scores? Communities with better developed supports

for wraparound show higher fidelity scores Training and coaching found to be associated

with gains in fidelity and higher fidelity Coaching is new to human services, but not to

the business community Coaching is hands-on instruction to the

Wraparound Staff

The Wraparound Staff… Wraparound Facilitators Family Support Partners Youth Support Partners Supervisor/Coach We support the supervisor/coach to be able to

credential their own staff and ensure that they are competent at the wraparound process

Are Wraparound Staff Culturally Competent? Cultural competence is often misunderstood Cultural competence is often seen from a race

or ethnicity focus only Cultural competence includes race, ethnicity,

family culture and preferences

Levels of CultureLevel One: Living preferences, traditions,

hobbies, activities, spiritual choicesLevel Two: Family rules, expected behaviors,

historical patterns of resilience, how decisions are made, etc.

Level Three: Family handling crises/trauma, how family deals with stress

Evidence-Based Practices The term evidence-based practice (EBP),

refers to preferential use of behavioral health interventions for which systematic empirical research has provided evidence of statistically significant effectiveness as treatments for specific problems.

Practice-based Evidence “a range of treatment approaches and supports

that are derived from, and supportive of, the positive cultural attributes of the local society and traditions. Practice based evidence services are accepted as effective by the local community, through community consensus, and address the therapeutic and healing needs of individuals and families from a culturally-specific framework.” (TA Partnership)

Wraparound is both EBP and PBE Most states now accept high fidelity

wraparound as an accepted EBP. There are more children, youth, and families in wraparound than all other EBP combined (Suter, 2007).

Wraparound is unique in that it comes from both a research and a community culture competent perspective.

Greater/more rapid achievement of permanency when implemented in child welfare (Oklahoma)

More successful integration of adult prisoners into the community (Oklahoma)

Reduction in costs associated with residential placements (LA County, Maine, Kansas, many other jurisdictions), with increases in child functioning 29

Examples of outcomes of wraparound

Outcomes in Washington State With Wraparound Pilot families, significant

positive reductions in school attendance, reductions in property damage, thefts, and behavioral health status

Fidelity Scores exceed national norms

(From the Evidence Based Practice Institute, University of Washington)

Innovations in Residential Treatment Centers in Systems of Care Communities

A very rapid national shift with residential treatment from longer term care to brief, individualized stabilization focused services

This shift is nothing new to field, but the degree of residential involvement with the Wraparound Process is new

Current Issues in Residential Care

There is a place in the System of Care for Residential Treatment Services (RTS)

The overall North American use of RTS is decreasing The use of long term (more than 90 days LOS) RTS is

decreasing most rapidly in states with greater use of intensive individualized services (e.g, wraparound) and fiscal incentives for shorter term care

As a result, the definition and scope of RTS roles are changing in SOC communities. Maine has achieved major progress in this area

• Due to the use of high fidelity wraparound, family group decision making, restorative justice, and other innovative supports, done in an Integrated model, Maine has gone from 780 youth in long term out of home care to less than 50, in under three years.

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Maine

Absolutely, but it is different than in pre-wraparound days.

In states with strong wraparound process efforts, although huge numbers of youth are diverted from RTS, out of home stabilization during crisis is sometimes needed. Youth with few permanency options may need RTS for a short term basis while a permanency option is created.

RTS which “play well with wraparound” and offer short term stabilization with highly individualized, family driven services will thrive*

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Is there a place for Residential?

Some sites with highly effective and efficient high fidelity wraparound processes are seeing close to 100% drops in referrals to RTS (for example, El Paso County, Colorado – one of the most integrated sites in the U.S. – Six systems all doing wraparound in exactly the same way, with the same principles, phases and activities, and skill sets)

This means that re-engineering of RTS will be necessary for survival of the RTS focused organizations.

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Integration and Re-Engineering of RTS

RTS Agency in Ft. Collins, Colorado. Mountain Crest was close to closure in 2007 Adapted wraparound as a practice model,

highly individualized short term placements became more attractive to referral sources, now has waiting list

Started new services of out-patient based wraparound facilitation, and other community based services. 36

Example of Re-Engineering

Wraparound with Residential on Team

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Residential

Treatment Center

Individualize

d Accountable

to Team

Child and Family Team

- Single - Permanency

Plan

Community

Resourcesand

Community Based

Providers

Birth Family,

Adoptive Family,Foster

Family and Natural Supports

A single plan guides the supports and services in all settings

Big Lessons… The more complex the needs of the family/youth,

the more individualized the plan must be. The opposite is standard practice in most systems

The more complex the needs of the family/youth, the more integrated the plan must be to ensure positive outcomes. In fact, current practice reveals lower integration with high complexity families.

Assessing family culture and using that culture in a strengths-based, individualized and integrated plan produces stronger outcomes