Engaging families and Engaging families and

engaging servicesengaging services

Presented byPresented by

Mary McKay, PhDMary McKay, PhD

Mount Sinai School of Mount Sinai School of MedicineMedicine

AcknowledgementsAcknowledgements

Richard Hibbert, MSW, Myla Harrison, Richard Hibbert, MSW, Myla Harrison, M.D., Anthony Salerno, Ph.D., CHAMP M.D., Anthony Salerno, Ph.D., CHAMP collaboratorscollaborators

New York State Office of Mental Health New York State Office of Mental Health & National Institute of Mental Health& National Institute of Mental Health

Welcome and IntroductionsWelcome and Introductions

Identify 1 obstacle that you have Identify 1 obstacle that you have encountered as you tried to encountered as you tried to involve youth and their families in involve youth and their families in services.services.

Mental Health and ChildrenMental Health and Children

Two thirds of children in need of Two thirds of children in need of mental health care do not receive mental health care do not receive services.services.

No show rates can be as high as No show rates can be as high as 50%.50%.

Drop outs occurring after two or Drop outs occurring after two or three sessions are common.three sessions are common.

The Research: Barriers to Involvement The Research: Barriers to Involvement in Child Mental Health Interventions in Child Mental Health Interventions

(Urban Settings)(Urban Settings)

Triple threat: poverty, single parent Triple threat: poverty, single parent status and stressstatus and stress

Concrete obstacles: time, transportation, Concrete obstacles: time, transportation, child care, competing prioritieschild care, competing priorities

Attitudes about mental health, stigmaAttitudes about mental health, stigma Previous negative experiences with Previous negative experiences with

mental health or institutionsmental health or institutions

The Research: Barriers to Involvement The Research: Barriers to Involvement in Child Mental Health Interventions in Child Mental Health Interventions

(Rural Settings)(Rural Settings)

Scarce mental health resourcesScarce mental health resources TransportationTransportation Stigma associated with mental illness Stigma associated with mental illness

and seeking careand seeking care Concerns about confidentialityConcerns about confidentiality IsolationIsolation

Empirically supported Empirically supported Engagement InterventionsEngagement Interventions

Focused telephone procedures associated Focused telephone procedures associated with increased initial show rates with increased initial show rates

Structural family therapy telephone Structural family therapy telephone engagement intervention associated with engagement intervention associated with 50% decrease in initial no show rates and 50% decrease in initial no show rates and a 24% decrease in premature a 24% decrease in premature terminations (Szapocznik, 1988; 1997; terminations (Szapocznik, 1988; 1997; 2004)2004)

Summary:Summary: Telephone Telephone Engagement Strategies Engagement Strategies

to Address Barriersto Address Barriers

““First Telephone First Telephone Contact”Contact”

Telephone Engagement Telephone Engagement InterventionIntervention

Intervention during the initial telephone Intervention during the initial telephone intake or appointment callintake or appointment call

Relies on an understanding of child, Relies on an understanding of child, family, community and system level family, community and system level barriers to mental health carebarriers to mental health care

Goals: Goals:

1) clarify the need for mental health care 1) clarify the need for mental health care

2) increase caregiver investment and 2) increase caregiver investment and efficacyefficacy

Telephone Engagement Telephone Engagement Intervention (cont.)Intervention (cont.)

Goals: Goals:

3) Identify attitudes about previous 3) Identify attitudes about previous experiences with mental health care experiences with mental health care and institutions and institutions

4) PROBLEM SOLVE! PROBLEM SOLVE! 4) PROBLEM SOLVE! PROBLEM SOLVE! PROBLEM SOLVE! around concrete PROBLEM SOLVE! around concrete obstacles to careobstacles to care

What needs to happen on What needs to happen on the telephone?the telephone?

Referral to treatmentReferral to treatment– Help parents invest Help parents invest

initially in treatment initially in treatment for their childfor their child

– Help parents and Help parents and child invest in child invest in ongoing work with ongoing work with providerprovider

– Problem Solving! Problem Solving! Problem Solving!Problem Solving!

Clarify needs of child and Clarify needs of child and familyfamily

Perception of concernPerception of concern– How LongHow Long– Where – at home – at Where – at home – at

school – with friends- school – with friends- with other adultswith other adults

Perception of services Perception of services and “helpers”and “helpers”– Relationship with Relationship with

teachersteachers– Previous therapy Previous therapy

experiences (either kids experiences (either kids or adults)or adults)

– Previous experience with Previous experience with helping providershelping providers

Needs of the child and family Needs of the child and family (cont.)(cont.)

Defining concernDefining concern– Recent exampleRecent example– Why nowWhy now– Strengths in Strengths in

supporting childsupporting child– Things parent has Things parent has

tried in the pasttried in the past

Getting helpGetting help– Can services Can services

make a difference make a difference for the childfor the child

– Have they sought Have they sought help beforehelp before

– Was that Was that experience experience helpful; was the helpful; was the provider helpfulprovider helpful

Getting ready for the Getting ready for the appointment: appointment: Assignments for the Assignments for the

Caretaker & Appointment ScheduledCaretaker & Appointment Scheduled

Make a list of:Make a list of: StrengthsStrengths GoalsGoals ConcernsConcerns Discuss coming to the appointment Discuss coming to the appointment

with your child.with your child.

•Time•Date•Intake Worker•Address•Directions by car, bus, and subway

Basics of Active Problem Basics of Active Problem SolvingSolving

What do you think about coming?What do you think about coming? What could stand in the way of getting here?What could stand in the way of getting here? How are you going to get here?How are you going to get here? Who are you going to bring?Who are you going to bring? How will these people feel about coming?How will these people feel about coming?

Basics of Active Problem Basics of Active Problem SolvingSolving

What time is best for you?What time is best for you? Will this interfere with anything else?Will this interfere with anything else? How comfortable do you feel talking about your How comfortable do you feel talking about your

child’s needs?child’s needs? How hopeful do you feel that this will help?How hopeful do you feel that this will help?

Preparation for the first meeting Preparation for the first meeting is key!is key!

Getting ready for the first Getting ready for the first meetingmeeting– Meet with our staff to get a Meet with our staff to get a

better idea of how (facility, better idea of how (facility, treatment, services) can be treatment, services) can be helpful. helpful.

– Will spend some time filling Will spend some time filling out forms (i.e. insurance, out forms (i.e. insurance, basic info, etc.) basic info, etc.)

– Will spend more time Will spend more time talking with parent, child, talking with parent, child, and other family members and other family members so that we can come up so that we can come up with a plan to help (child’s with a plan to help (child’s name).name).

– How does that sound?How does that sound?

Important considerations Important considerations throughout the telephone throughout the telephone

interviewinterview RaceRace Ethnicity/cultural issuesEthnicity/cultural issues StressorsStressors IsolationIsolation Fears that friends, Fears that friends,

neighbors will neighbors will disapprove of seeking disapprove of seeking carecare

Helping client manage Helping client manage in communities of in communities of scarce resourcesscarce resources

Telephone Engagement Telephone Engagement Study MethodsStudy Methods

Outcome of interest: # of families Outcome of interest: # of families that came to an initial appointmentthat came to an initial appointment

Setting: outpatient child mental Setting: outpatient child mental health clinichealth clinic

Sample: Sample: nn=54=54 Design: Matched comparison of Design: Matched comparison of

consecutive referrals in one monthconsecutive referrals in one month

Telephone Engagement Study Telephone Engagement Study ResultsResults

21

6

1314

0

5

10

15

20

25

Engage Compare

# of children broughtto first session (n=27per condition)no show

Telephone Engagement Telephone Engagement Study #2 MethodsStudy #2 Methods

Outcome of interest:Outcome of interest: # of families # of families that came to an initial appointmentthat came to an initial appointment

Setting:Setting: Outpatient child mental Outpatient child mental health clinichealth clinic

Sample:Sample: nn=108=108 Design:Design: random assignment to random assignment to

conditioncondition

Telephone Engagement Telephone Engagement Study #2 ResultsStudy #2 Results

40

15

24

29

0

5

10

15

20

25

30

35

40

Engage Compare

# of families that cameto 1st appt.No show

Exercise 1: Barriers to Exercise 1: Barriers to child/family engaging in the child/family engaging in the

helping processhelping process

Instructions for participants:

•List 5 – 10 obstacles that would prevent a child from wanting to come to a treatment appointment.•Next, list 5 – 10 obstacles that would interfere at the parent/family level in getting to a treatment appointment.

•What new strategies can you develop to help families address obstacles?

Exercise 2: What would make a Exercise 2: What would make a families’ experience perfect at your families’ experience perfect at your

site?site?

Instructions for participants:

Imagine you are a parent calling to get services at your agency for the first time. Describe what would make the experience perfect for that parent and child. Start your description with the phone call and include your arrival to the agency waiting room but end at the point you are called to meet the intake worker.

First Interview Engagement First Interview Engagement StrategyStrategy

Summary: Engagement Summary: Engagement Approach to Involving Approach to Involving

Children and their Children and their Families Families

First InterviewFirst Interview

Vulnerable populationsVulnerable populations

The most vulnerable child populations, in The most vulnerable child populations, in terms of seriousness of presenting terms of seriousness of presenting problems or complexity of social problems or complexity of social situations, are less likely to be retained situations, are less likely to be retained beyond the 1beyond the 1stst mental health session mental health session

The delivery of services to vulnerable The delivery of services to vulnerable client populations rests on the client populations rests on the engagement of clients in the helping engagement of clients in the helping process.process.

Vulnerable populations Vulnerable populations (cont.)(cont.)

Therefore it is critical for interviewers to Therefore it is critical for interviewers to develop and utilize focused culturally develop and utilize focused culturally sensitive engagement skills that address sensitive engagement skills that address the range of barriers that can exist within the range of barriers that can exist within families, environments, and agencies families, environments, and agencies interfering with the process of engagement.interfering with the process of engagement.

A protocol for first/engagement interviews A protocol for first/engagement interviews was developed and tested with the was developed and tested with the following results.following results.

Purpose of first interview Purpose of first interview engagement strategy engagement strategy

Two primary Two primary purposes:purposes:– To understand why To understand why

a child and family a child and family want help from want help from provider.provider.

– To engage the child To engage the child and family in a and family in a helping process, if helping process, if appropriate.appropriate.

Four Critical Elements of the

Engagement Process

Element – 1 Element – 1 Clarify the helping Process for the client…Clarify the helping Process for the client…

Carefully introduce self, agency intake process, and Carefully introduce self, agency intake process, and possible service options.possible service options.

Do not assume that client has been given accurate Do not assume that client has been given accurate information about services.information about services.

Do not assume clients know what is expected of them and Do not assume clients know what is expected of them and what they should expect from intake process/workerwhat they should expect from intake process/worker

Element – 2 Element – 2

Develop the foundation for a Develop the foundation for a collaborativecollaborative working relationship… working relationship…

Balance the need to obtain intake information Balance the need to obtain intake information (agency assessment, insurance forms, etc.) with (agency assessment, insurance forms, etc.) with helping the child and family to “tell their own story” helping the child and family to “tell their own story” about why they have come.about why they have come.

Element – 3 Element – 3 Focus on immediate, practical concerns…Focus on immediate, practical concerns…

Be ready to schedule a second appointment sooner than the Be ready to schedule a second appointment sooner than the following week.following week.

Parents often need help negotiating with other “systems” (i.e. Parents often need help negotiating with other “systems” (i.e. school).school).

Responding to parents concerns provide an opportunity for Responding to parents concerns provide an opportunity for worker to demonstrate their commitment and potential worker to demonstrate their commitment and potential capacity for help.capacity for help.

Element – 4 Element – 4 Identify and problem-solve around barriers to help Identify and problem-solve around barriers to help

seekingseeking Every first interview must explore potential barriers to Every first interview must explore potential barriers to

obtaining ongoing servicesobtaining ongoing services Specific obstacles, such as time and transportation must be Specific obstacles, such as time and transportation must be

addressed.addressed. Other types of barriers include previous negative experiences Other types of barriers include previous negative experiences

with helping professionals; discouragement by others to seek with helping professionals; discouragement by others to seek professional help; differences in race or ethnicity between the professional help; differences in race or ethnicity between the interviewer and the client; families experiences with racism interviewer and the client; families experiences with racism and its impact on their willingness to receive services from a and its impact on their willingness to receive services from a “system” need to be carefully explored.“system” need to be carefully explored.

First Interview Study First Interview Study MethodsMethods

Outcome of interest: # of families Outcome of interest: # of families that came to initial and ongoing that came to initial and ongoing appointmentsappointments

Setting: Outpatient child mental Setting: Outpatient child mental health clinichealth clinic

Sample: Sample: nn=107=107 Design: Random assignment to Design: Random assignment to

conditioncondition

First Interview ResultsFirst Interview Results

0

20

40

60

80

100

120

Accepted 1st Appt. 2nd Appt. 3rd Appt.

% for first interview(n=33)% for comparison(n=74)

Collaborating with families to enhance Collaborating with families to enhance outpatient mental health and school based outpatient mental health and school based

servicesservices

• Multiple family group approachesMultiple family group approaches

Multiple family groupsMultiple family groups

• Target family factors that have been Target family factors that have been empirically linked to childhood conduct empirically linked to childhood conduct difficultiesdifficulties

• Focus on practical parenting strategies that Focus on practical parenting strategies that can be immediately incorporated in order to can be immediately incorporated in order to reduce stress and increase optimismreduce stress and increase optimism

• Build upon family strengths and reduce Build upon family strengths and reduce stigmastigma

• Address barriers to service use via active Address barriers to service use via active problem solvingproblem solving

In the words of families…In the words of families…

Multiple family groups should focus on:Multiple family groups should focus on:• RRulesules• RRoles and Responsibilitiesoles and Responsibilities• RRespectful communicationespectful communication• RRelationshipselationships

Multiple family group intervention Multiple family group intervention outlineoutline

Session 1Session 1 What are multiple family What are multiple family groups?groups?

Session 2Session 2 Building on family strengthsBuilding on family strengths

Session 3Session 3 Rules for home and schoolRules for home and school

Session 4Session 4 Responsibility at home and at Responsibility at home and at schoolschool

Session 5Session 5 RelationshipsRelationships

Session 6Session 6 Respectful communicationRespectful communication

Session 7Session 7 Dealing with stress at homeDealing with stress at home

Session 8Session 8 Who can we turn to (building Who can we turn to (building supports)?supports)?

Multiple family group intervention Multiple family group intervention outlineoutline

Session 9Session 9 Fixing broken rulesFixing broken rulesSession 10Session 10 Everyone does their share in Everyone does their share in

solving problemssolving problemsSession 11Session 11 Building kids upBuilding kids upSession 12Session 12 Everybody gets a chance to be Everybody gets a chance to be

heardheardSession 13Session 13 Dealing with stress/Finding Dealing with stress/Finding

resourcesresourcesSession 14Session 14 Stress & resources - Part IIStress & resources - Part IISession 15Session 15 How did group go?How did group go?Session 16Session 16 Ending partyEnding party

MFG study methodsMFG study methods

• Outcome of interest:Outcome of interest: % of families in % of families in attendance & child mental health attendance & child mental health symptomssymptoms

• Setting:Setting: urban outpatient child mental urban outpatient child mental health clinichealth clinic

• Sample:Sample: nn=88 =88 • Design:Design: consecutive referrals for consecutive referrals for

conduct difficulties were assigned first conduct difficulties were assigned first to MFG until spaces filled and then to to MFG until spaces filled and then to services as usualservices as usual

Results: % Involvement in MFGs vs. Results: % Involvement in MFGs vs. Clinic ComparisonClinic Comparison

10091

59

9584

39

0

20

40

60

80

100

120

ever 3 sessions 16 sessions

MFG (n=34)Comparison (n=54)

Changes within child serving Changes within child serving systemssystems

Overview of Overview of engagement teamsengagement teams

Collection of data Collection of data related to related to engagementengagement

Quality Mental Health Quality Mental Health ServicesServices

Consumer CenteredConsumer Centered

Knowledge Based / Data DrivenKnowledge Based / Data Driven

System OrientedSystem Oriented

Definition of qualityDefinition of quality

The degree to which health services The degree to which health services for individuals and populations for individuals and populations increase the likelihood of desired increase the likelihood of desired health outcomes and are consistent health outcomes and are consistent with current professional knowledge.with current professional knowledge.– IOM, 1990IOM, 1990

Model of quality Model of quality improvementimprovement

Shifts away from retrospective Shifts away from retrospective methods to concurrent and/or methods to concurrent and/or prospective approachesprospective approaches

Continuous Quality ImprovementContinuous Quality Improvement

The continuous quality improvement The continuous quality improvement cyclecycle

Plan

Check

Inpu

t

CQI cycleCQI cycle

Plan – define organizational plan for Plan – define organizational plan for quality tied to customer needs.quality tied to customer needs.

Do – improve organizational Do – improve organizational performance on key indicators.performance on key indicators.

Check – assess how well the services Check – assess how well the services delivered in “DO” phase accomplished delivered in “DO” phase accomplished the objectives in “PLAN” phase.the objectives in “PLAN” phase.

Act – evaluate and refine quality plan.Act – evaluate and refine quality plan.

Learning Collaborative Learning Collaborative Performance Indicator #1 Performance Indicator #1

((by month by month across 13 agencies)across 13 agencies)

59

7278 80

75 78

0102030405060708090

100

% of keptintake appts.(LearningCollaborativeMembers)

baseline

Estimates of number of children completing Estimates of number of children completing an intake as a result of quality an intake as a result of quality

improvements related to engagementimprovements related to engagement

216

264286 293

275 286

0

50

100

150

200

250

300

350

Oct

.Nov.

Dec.

Jan.

Feb.

Mar

.

baseline

all (representing324 more childrenthat received anintake over the 5-month LearningCollaborative)

Summary & Wrap-upSummary & Wrap-up

Final questions and answersFinal questions and answers