TCOM Conversations

Transformative Culture: The Call for Psychological Safety

By: Tiffany Lindsey, EdD, LPC-MHSP

Chapin Hall at the University of Chicago

Have you ever made a mistake at work—maybe even one that could have affected you, your teammate, or a client’s safety?

If you’re a human who helps other humans for a living, the answer is a prevailing yes. None of us do the work perfectly. Mistakes aren’t intentional, but it’s hard to get it right every time. Clinicians and human service professionals, in general, are tasked with making high-consequence choices at alarmingly fast rates. So I have another question:

Did you tell anyone about your mistake?

If you didn’t, you’re not alone. A healthcare study found, when confronted with a patient’s adverse outcome, most physicians are unwilling to admit an error (Gallagher, Garbutt, & Waterman, 2006). It’s hard to imagine disclosing mistakes to teammates would be much higher, even though processing a mistake and receiving feedback and support is crucial to professional development and gives teammates an opportunity to learn too.

There are lots of reasons why we aren’t prone to vulnerable disclosures—liability concerns, fear of seeming “less than” or incapable; in modern Western society, we tend to view colleagues as competitors. We’re hard-wired as children to think this way (remember those Spelling Bees?) not to mention Super Bowls wouldn’t be nearly as fun if we weren’t rooting for one team to win over the other. In Western society, we celebrate achievement over others and sweep our failures under a rug.  

While our competitive spirit isn’t all bad, spending time “saving face” is both dangerous and unhealthy. Talking about concerns, being honest about personal experiences, and processing undesired outcomes is central to innovation. Safe, engaged, reliable teams have to innovate to succeed in an increasingly complex and dynamic environment. Not only that, but consensus-based decision-making is a foundational element of TCOM. Such consensus involves reflection, engagement, and even some productive debate as the care team (which includes the client) reaches an understanding of the family’s story and shared vision for transformation. True, informed, consensus—without psychological safety—would be quite a challenging achievement, arguably an impossible one.

Psychological Safety: A Shared Experience

Psychological safety is a shared belief that people are accepted, supported, respected, and free to take interpersonal risks (Edmondson, 2019). While trust is about whether or not we believe others will behave supportively when we take an interpersonal risk, psychological safety is about a shared practice that others actually do behave supportively when those risks are taken.

Psychological safety seems simple, but the nuances are relevant. Consider the following attributes of psychological safety (Frankel, Haraden, Federica, & Lenoci-Edwards, 2017):

  • Anyone can ask questions without feeling stupid.
  • Anyone can solicit feedback without seeming incompetent.
  • Anyone can be respectfully candid about concerns without being viewed as “negative.”
  • Anyone can suggest ideas without sounding disruptive.

Google’s well-publicized study, Project Aristotle, was about identifying team factors central to successful innovation. For years, the research team investigated an array of variables (e.g., educational credentials, personality, gender, supervisor’s management style, professional experience) without an emerging theme. Then they stumbled onto psychological safety—it ended up being the single factor most predictive of a team’s success. Despite wide variations in the groups’ demographics, psychologically safe teams would brainstorm, test things (often failing but always while learning and progressing) and, therefore, arrive at successful ideas sooner. Such teams demonstrated situational humility and conversational turn-taking—meaning every member spoke (albeit unintentionally) about the same amount throughout the week (Duhigg, 2016).

Psychological safety is the cornerstone of a Safety Culture—the attitudes, values, behaviors supporting a safe and engaged workforce. Though sometimes coined by other related names, like High Reliability Organizing, Human Factors, or Resilience Engineering, the pursuit of Safety Culture has a tremendous amount of evidence in high-risk industries. In healthcare, the presence of behaviors indicative of Safety Culture (see my last blog post for a list of those behaviors) correlates to fewer patient readmissions, patient falls, and medication errors (Vogus & Sutcliffe, 2011).

In child welfare, growing evidence suggests team-based Safety Culture behaviors correlate to the entries, exits, and re-entries of children in state care. In short, teams may experience more entries into state care but also might experience a higher percentage of exits, and fewer of those children re-enter (Lindsey, 2017).  Not surprisingly, psychological safety has an evidenced connection to burnout; in an analysis of child welfare professionals, higher psychological safety correlated to less emotional exhaustion (Cull, 2018).

In considering whether or not the culture of your workplace supports psychological safety, think through these statements (Edmondson, 2019):

  • If someone makes a mistake, is it often held against them?
  • Can people bring up problems and tough issues?
  • Is it difficult to ask others for help?
  • Is it safe to take an interpersonal risk?
  • Are peoples’ unique skills and talents used?

You might find the answers are different as you consider different teams or hierarchies within your organization. Some people feel psychological safety among their small cohort (i.e., a team of counselors reporting to one supervisor, a single unit within a psychiatric hospital) but unsafe among another unit or perhaps a group of leaders.

Cultivating Psychological Safety

Psychological safety is a shared experience. We can all support it, but none of us can singlehandedly accomplish psychological safety alone. It’s not an intrapsychic experience; it’s an interpersonal one. Leaders are capable of the most widespread change, but all people are responsible for culture. And like most cultural phenomenon, it’s a journey of improvement and not a single stroke destination.

If you’re looking for some ways to improve psychological safety to advance a safety culture in your workplace, consider these possibilities:

  • Be present. Psychologically safe cultures value active listening, situational humility, and empowering people to exercise voice when they have a concern.
  • Language drives culture, so be intentional about it. Rather than refer to a direct care workforce as “workers,” consider the term “professionals.”
  • Cultivate avenues for “speaking up.” This may look like confidential reporting systems, where people can privately (but not anonymously) report safety issues. It may also look like “Resilience Rounds,” where leaders step out of the executive suite and meet informally with frontline professionals to model values, express appreciation, and check-in about frontline’s needs.
  • Be wary of bias. While it’s impossible to entirely avoid, self-awareness is key. Hindsight, outcome, and fundamental attribution error are among the worst.
  • Gossip is the pollution of good culture and yes—you can be held guilty by association. Candidly and respectfully ask those who gossip to stop.
  • When looking into an undesirable client outcome, lead for learning and offer support to professionals assigned to the client. Conduct “studies” instead of “investigations.”
  • Consider Psychological Safety and Accountability concurrent experiences; they are best practiced together. It’s not a balance so much as an integration. If you have 11 minutes, watch this video to learn what I mean.

References

Cull, M. (2018). Casey Family Programs: Child safety convening. Keynote Speaker.

Duhigg, C. (2016). What Google learned from its quest to build the perfect team. Retrieved from: https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html.

Galler, T., Garbutt, J., & Waterman, A. (2006). Choosing your words carefully: How physicians would disclosure harmful medical errors to patients. Arch Intern Med, 166: 1585-1593.

Edmondson, A. (2019). The fearless organization. Wiley: New York, NY.

Frankel, A., Haraden, C., Federica, F., & Lenoci-Edwards, J. (2017). A framework for safe, reliable, and effective care. White Paper. Healthcare Improvement and Safe & Reliable Healthcare: Cambridge, MA

Lindsey, T. (2018). The effects of safety culture on the outcomes for children in state care. Available from ProQuest Dissertations & Theses Global (10750794).

Vogus, T., & Sutcliffe, K. (2011). The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Journal of Nursing Administration, 41 (7/8), S25.

Registration is Open! #TCOM2019

We are so excited to announce registration for our 15th annual TCOM Conference in Palm Springs is now open!

Culture and Community: Sharing Stories from the Collaborative

Every year the TCOM Conference provides an opportunity to collaborate with and learn from leaders and innovators in behavioral health, child welfare, education, juvenile justice, and more. While we all have a shared passion for serving youth and families, we each bring a unique perspective to the table. This year’s theme, “Culture and Community: Sharing Stories from the Collaborative” reminds us that it is incumbent upon us to understand, to the best of our abilities, the impact of cultural and community factors on the applications of our common language and shared approaches.

This year, for the first time, we will be offering a unique and exciting Pre-Conference Day consisting of master lectures and a series of round table discussions! You won’t want to miss it! More session and presentation details will be published over the coming weeks.

Register NOW to take advantage of Early Bird Rates–offer ends June 30th!

  • Pre-Conference (Oct. 2) $180
  • Pre-Conference + Day 1 (Oct. 2 & 3) $340
  • Day 1 + Day 2 (Oct. 3 & 4) $240
  • Full Conference (Oct 2-4) $336

The Praed Foundation has applied for continuing education credits through NBCC. Confirmation of credit hours available will be posted in August.

Book your stay at the Hyatt Regency Indian Wells Resort & Spa!

Sponsorships

The annual TCOM Conference isn’t possible without the generous support we’ve received over the years. If you are interested in becoming a sponsor, please reach out to communications@praedfoundation.org or check out our Sponsorship Guide.

Defining Serious Mental Illness

By: Beth Anne Nichols, NH Mental Health Block Grant Plan Administrator

New Hampshire Department of Health and Human Services

In the rugged landscape that is New Hampshire’s mental health system, serious mental illness (SMI) is a powerful thing. On an individual level, an adult experiencing SMI becomes eligible for community-based psychiatric rehabilitation. Psychiatric rehabilitation consists of an array of services reimbursable by NH Medicaid alone. The privately insured may access these services via a sliding fee scale – if they are assessed and determined to be SMI.

The capstone of NH’s Community Mental Health provider programs is the case management and treatment for our SMI population.

If the ten Community Mental Health Centers (CMHC) are the spokes in the sturdy wheel of the SMI treatment services system, the hub of the wheel is the NH Department of Health and Human services (NH-DHHS).

The NH-DHHS has established the Adult Needs and Strengths Assessment (NH-ANSA) as the instrument that informs and directs the treatment, and records the treatment outcomes, of the thousands of SMI adults in the care of the CMHCs.

In the world of psychiatry, the classification of mental illnesses changes as the body of knowledge, experience, and science evolve. But the federal government’s – and the state of NH’s – definition of “Serious Mental Illness” has remained unchanged for decades. Labeling someone as “Seriously Mentally Ill” can create nearly as many social and vocational barriers as it does opportunities for psychiatric rehabilitation.

Into this world of mixed blessings comes the NH-ANSA.  The original vision for the NH-ANSA was to serve as a standard for determining the presence of SMI, serving as the “ticket” to psych-rehab services like the valuable case management and “functional supports” provided in the community, at home, or in the workplace. Increasingly– as the treatment focus for a large portion of the SMI population under our care follows a progression of symptom management to functional improvements, especially employment stability– tracking impairment needs and improved functioning has assumed a high priority.

For NH community mental health programs, the ANSA, as a periodic measuring stick of symptom and functioning, has replaced a narrative annual assessment of functioning (though not without resistance!).  Gradually, the CMHCs and growing numbers of their partners, are using the NH-ANSA to chart a path toward clear reporting of treatment and recovery trajectories. The NH-ANSA provides a sound objective basis for program screening based not only on diagnosis, but on levels of need and clusters of impairments that clearly inform treatment planning, and outcomes goals across the service system.

The NH ANSA to the Rescue

The federal definition of serious mental illness was created to assist in the determination of eligibility for Social Security disability benefits.  Specifically, assessment of impairments interfering with the ability to maintain employment or other “major life activities” were a key component for Social Security disability determinations. New Hampshire embraced these criteria because of the strong link between Social Security and Medicaid.

Psychiatric diagnosis and symptoms form a slice of SMI criteria; the degree of “functional impairment” contributing to disability caused by mental illness is a much larger slice.  The ANSA, with the elemental nature of its Life Functioning domain, provides an objective yardstick.

For those who are interested, NH’s SMI criteria are laid out in He-M 401 of our “Administrative Rules”.  These criteria were the basis for the work of New Hampshire and Dr. John Lyons to crosswalk SMI requirements into the NH-ANSA.

Collaboration between an individual, their natural supports, and their treatment team to craft a treatment and recovery trajectory based on the ANSA removes the directive and top down nature of the narrative assessment previously employed by our providers.

Today the State of NH continues to collaborate with our providers and the Praed Foundation to polish the assessment instruments that can order the landscape of our mental health service system. The NH-ANSA, with its efficiency and objectivity, strengthens the foundations recovery for our SMI adults. 

Appendix

Tiffany Lindsey

Meet Tiffany Lindsey!


Tiffany Lindsey is licensed professional counselor working as a Policy Analyst for Chapin Hall. She collaborates with child serving agencies to implement the strategies of safety science to create a Safety Culture in child welfare work. Prior to this, Tiffany was a quality improvement director for the Tennessee Department of Children Services. She was foundational to the creation and successful implementation of a critical incident review model acknowledged as a “gold standard” in child death reviews. Tiffany was a primary contributor to the development of the Safe Systems Improvement Tool—the Praed Foundation’s first-of-its-kind, multipurpose, information integration tool for use in quality improvement activities.

Tiffany serves as adjunct faculty in the School for Graduate and Continuing Studies at Trevecca Nazarene University and owns a small mental health counseling practice in Lebanon, Tennessee. She enjoys equestrian events in her spare time and partners with her husband, Jesse, in competitive ballroom dancing. Jesse and Tiffany have a daughter, Cadence, and live in Mount Juliet, Tennessee.

Tiffany holds a Doctor of Education in Leadership and Professional Practice from Trevecca Nazarene University, a Master of Arts in Marriage and Family Therapy/Professional Counseling from Johnson University and a Bachelor of Art in Counseling from Johnson University.

You can reach Tiffany by contacting her at tlindsey@chapinhall.org!

Other posts written by Tiffany Lindsey

TCOM and Systems Safety: My Journey

By: Tiffany Lindsey, Policy Analyst

Chapin Hall at the University of Chicago

My journey towards Safety Culture began in a group home.

I was 24-years-old and had just started a new job as program manager—my first supervisory role. I was the only clinician on-site. All but one of my staff were older than I was, and the group home appeared on the verge of closure. Per state auditors, no new admissions were allowed in the facility until we had things “cleaned up.” From what I could tell, it was going to be a very long Performance Improvement Plan.

I worked there constantly, sometimes just sleeping a few hours on the couch in my office rather than drive home. The group home housed 8 adolescent females. Every night it seemed one or more of the girls were self-harming, fighting, sneaking in contraband, or running away. It wasn’t uncommon to find staff crying in the office. I honestly wanted to cry several times myself but was too overwhelmed for the tears to come out.

My boss, Kim, was new to supervising both me and the group home. She was compassionate, assertive, calm, and smart. She was in charge of several programs and did not work at my location, but I remember calling her several times in the middle of the night:

Kim: Hey Tiffany.

Me: It’s crazy here, Kim. I don’t know what to do… [insert rambling, hurried, nearly nonsensical story]

Kim would always help me solve the crisis quickly, even if it meant she traveled out to help me in the middle of the night. She was never mad at me or my staff, even if we had made mistakes (which we often did). She always wanted to talk through it and help us plan ahead for the next time. After all the residents were in bed, Kim and I would finish up documentation at 3-4am. During one of those times, she said:

“I want you to learn to think beyond these crises, Tiffany. Get upstream. Take a problem and ask yourself why it occurs. Then, whatever that is, ask yourself why it occurs. Keep doing that until you think you’ve found a systems issue we can reasonably tackle.”

Kim was an amazing mentor to me and my teammates. At the time, neither she nor I knew anything about the Safety Sciences or Safety Culture. Without knowing it, she was instilling in us the habits consistent with a Safety Culture. Those team-based habits are:

  1. Candor and respect are preconditions to teamwork.
  2. Spend time identifying what could go wrong.
  3. Talk about mistakes and ways to learn from them.
  4. Discuss alternatives to everyday work activities (i.e., finding efficiencies, testing out small iterative changes).
  5. Develop an understanding of “who knows what” by communicating clearly.
  6. Appreciate colleagues and their unique skills.

Those habits became the basis for all our improvements at the group home. Rather than blame the residents or fire a bunch of staff, we solved all the underlying systemic issues we could. We changed our staffing pattern, hired more PRN staff and targeted our employee recruitment at MSSW programs, created a new treatment process and positive reinforcement-based behavioral program for residents, and reallocated some resources to foster more safety in community outings. We did far more than that, but those changes alone made a huge difference. Our group home held a sense of community and pride.

I intend for this blog to be the start of a new featured series on System Safety and Safety Culture. There are several core values (e.g., psychological safety), quality improvement tools (e.g., driver diagrams, TCOM’s Safe Systems Improvement Tool), and team-based strategies (e.g., huddles, debriefs) useful in the interdependent, high-risk work of human services. In every way, the TCOM values of shared language, honest and respectful communication, and collaboration are parallel to the values of Safety Culture.

I’m going to make a bold claim: Safety Cultures are the best cultures to support TCOM. Where there is one, there needs to be the other. With that in mind, I trust I’ll find some kindred spirits among TCOM’s thriving community. I’m the “new girl on the block” with the TCOM Team, but you already feel like home. 

Thanks for welcoming me into the TCOM community!

Tiffany

TA Network Webinar: Effectively Integrating the CANS into the Wraparound Process

Date/Time: April 30, 2019, 11am – 12:30pm PT / 2pm – 3:30pm ET

The Wraparound process is the most common care coordination model for youth with complex needs and their families. Meanwhile, the Child and Adolescent Needs and Strengths (CANS) is now the most widely used assessment tool in public child-serving systems. While some states, systems, and organizations have determined how the Wraparound and CANS philosophies can co-exist and enhance each other, others have struggled, undermining the potential for positive impact of both efforts.

This webinar is based on shared work of the National Wraparound Implementation Center (NWIC) and Chapin Hall at the University of Chicago (organizational home of the CANS) to develop a guidance document around how to best integrate the CANS into the Wraparound process. The webinar will follow the “joint statement” from NWIC and Chapin Hall, and begin with a brief summary of how differences in the Wraparound and TCOM philosophies may raise “operational frictions” and problems in practice. Presenters will describe potential ways to effectively coordinate the CANS assessment with Wraparound practice – including “Do’s” and “Don’ts” – across the four phases of Wraparound.

Click here to register!

The Joy of Saying Goodbye

This is a farewell blog post about our teammate and friend who is leaving Chapin Hall at the University of Chicago for an exciting new opportunity. Katherine “Katie” Sun joined the TCOM Team in the summer of 2016. Since then, she launched communications platforms, including this blog, to expand the work and voices of the entire TCOM Collaborative.

Katie Sun

Katie has been a key member of the TCOM team for almost three years. With her big heart and good humor she has been the social glue of both the team at Chapin Hall and the larger international TCOM community. In addition to successfully launching this platform, she has organized and supported the annual TCOM Conference since 2017. It has become a stronger and more effective event with her steady, guiding hand. But her most important contribution to our work may be less about the big, visible things and much more about the way she carries herself in all of her interactions with others. She is kind and respectful to everyone no matter their role. She is always willing to go beyond her duties to extend a hand to someone in need. We often say that the helping field is the work of angels. Katie is truly one of those.

We recognize her many contributions to our work and will miss her presence in our daily lives. But in the TCOM frame saying goodbye is as important as saying hello—and often saying goodbye is a much more joyous occasion than any welcoming. We are very happy to see Katie’s life and career evolving in the direction of her aspirations. From a TCOM perspective, it is all of our responsibilities to support each other in becoming our best selves. Aspirational management is core to our approach. We are happy that she is following her dreams and wish her nothing but the best in her future endeavors. We celebrate that we have had Katie Sun as a part of our lives and know that she will continue to have a positive impact on the lives of others as her journey continues.

The TCOM Team

For continued TCOM communications connections, contact communications@praedfoundation.org.

Marrianne McMullen

Meet Marrianne McMullen!


Marrianne McMullen is the Director of Communication and Dissemination for Chapin Hall. McMullen drives Chapin Hall’s communications strategy, including dissemination planning, media relations, branding, and effective use of digital platforms. She advises on the effective use of communication to manage change in systems to improve the lives of children, youth, and families.

McMullen came to Chapin Hall after serving in the Obama Administration at the Administration for Children and Families (ACF) at U.S. Department of Health and Human Services. There she served as the Deputy Assistant Secretary for External Affairs, overseeing the division’s 10 regional offices, and the news, digital, and FOIA departments in the Office of Communications. Prior to joining ACF, McMullen worked with the District of Columbia Public Schools as Chief of Staff for Public Engagement, and at the Service Employees International Union, where she was the Communication Director for Illinois before becoming a senior aide to the international president. Her journalism career included being the news editor at Sojourners magazine, a reporter at the Palladium-Item in Indiana, and the editor and co-publisher of The Dayton Voice, an alternative newsweekly in Dayton, Ohio.

McMullen holds a Master of Arts in Communications from the University of Dayton and a Bachelor of Science in Journalism from West Virginia University.

You can reach Marrianne by contacting her at mmcmullen@chapinhall.org!

Other posts written by Marrianne McMullen

 

A community gathers to learn how to prevent the trauma of high homicide rates

By: Marrianne McMullen, Director of Communication and Dissemination

Chapin Hall at the University of Chicago

Audrey Wright, a senior at North Lawndale College Prep High School in Chicago, described the unthinkable to an auditorium packed with 1,500 people. She lost her mother and brother to gun violence within three days. The following year, she lost her father.

“I was introduced to Peace Warriors at my school, and I now serve as its president,” she told those gathered to learn more about combating gun violence. The Peace Warriors support other students affected by gun violence, they run a summer jobs program and they “interrupt nonsense,” she said.

Core to their mission is to do condolence runs to students who lost a loved one, delivering sympathy and an opportunity to process their grief. Last year, in 183 school days, they did 178 condolence runs.

Members of the TCOM Collaborative know the devastating impact that violence has on families and their communities. The desire to prevent that traumatic violence is palpable in Chicago, which has had a level of homicide that exceeds other large U.S. cities. So when community members were invited to a session where Wright spoke, the large venue was quickly booked.

The gathering was called Cities Striving for Peace: What Chicago Can Learn from Five Big-City Mayors who Successfully Lowered Gun Violence. It was organized by Chicago CRED (Create Real Economic Destiny), an organization funded by the Emerson Collective, led by former U.S. Education Secretary Arne Duncan. Participants heard from mayors of five other cities who saw dramatic drops in gun violence during their tenures. The cities were Los Angeles, Minneapolis, New Orleans, Philadelphia, and Washington, DC.

The mayors–each of whom saw double digit reductions in homicide on their watch–presented a menu of programs and approaches that have potential for implementation in Chicago. But nothing was more striking in contrast to the other cities than Chicago’s homicide resolution rate—or the rate at which homicide cases were closed or resolved. Los Angeles had the highest resolution rate at 74%; DC was at 71%; Minneapolis came in at 67%; Philadelphia at 44%. Chicago’s homicide resolution rate was 17%.

“If the community doesn’t trust your police department, you are not a safe city,” said Betsy Hodges, the former mayor of Minneapolis. The right leadership for, and community trust of, the police department is critical, the mayors said. Adrian Fenty, former mayor of Washington, DC, credited much of DC’s homicide reduction to hiring the right chief: Cathy Lanier—a woman from the community who came up through the ranks.

Law enforcement, all mayors stressed, is only one piece of the puzzle. “Law enforcement is going to get you as far as it’s gotten you,” said Hodges of Minneapolis. “Every part of the city has to be engaged and you have to be focused on the causes.”

Residents of the most violent neighborhoods in Minneapolis were asked to develop their own community-based strategy to address crime. And then the city invested in those strategies. “It was public budgeting meets public safety,” said Hodges. And it worked. Minneapolis saw a 23% decrease in homicides under Hodges.

Former Los Angeles Mayor Antonio Villaraigosa pointed to a critical program called Summer Night Lights. “We opened eight, 16, then 32 parks in the places of highest gun violence in the city,” Villaraigosa said. “We were open from 7 pm to midnight, Wednesday through Sunday. It was midnight basketball on steroids. We did soccer, Zumba for moms, we had movies, we fed people. And we invited gang members. We said, ‘come to the park – you are welcome.’”

They saw a 75% reduction in gun violence in those neighborhoods. “There were problems from time to time,” Villaraigosa said. “We had a couple shootings near the park on nights when we were open.” The response to the problems was predictable: some people wanted to shut down the parks. “But we stuck with it because we knew it was working.”

Concentrating resources was also key, he added. Public safety dollars were not distributed evenly across Los Angeles. They were spent where they were most needed. L.A. also started an academy for former gang members. The police department objected to the academy, but the city did it anyway. As a result, retaliation shootings went down dramatically. Overall, homicides dropped by 48% while Villaraigosa was mayor.

Mitch Landrieu, former mayor of New Orleans, emphasized the need for early education not just on math and science, but on conflict resolution. “You have to create places where these young men have sustenance,” he said, whether that’s through music, recreation centers, libraries or other programs.

“If you give a kid love, opportunity, security, resources – they are going to act like everybody else in America who has all that,” said Landrieu. Homicides decreased by 25% under Landrieu’s watch.

Michael Nutter, the former mayor of Philadelphia, stressed the need to set an ambitious homicide reduction goal and to “hold yourself publicly accountable to reaching that goal.” Philadelphia took early public policy steps to ensure the positive re-integration of people who had served time in prison. The efforts ranged from “banning the box” on job applications that asked about criminal records, to providing tax credits to employers who hired returning citizens. Philadelphia saw a 24% decline in homicide rates under Nutter.

All of the mayors talked about the critical role of schools: from quality early education, to strong high school programs to keep kids engaged and in school. Fenty emphasized that the core of his anti-violence approach was to fix the public schools.

Nationally, we’re having a conversation about what constitutes an emergency, said Landrieu. “In the U.S. since 1980, 630,000 American citizens died as a result of guns. Many were murder. That’s more Americans than were killed in all of the wars of the 20th and 21st century. So, what’s the emergency?”

“This is what I believe,” said Arne Duncan. “I believe our actions don’t justify us saying ‘black lives matter.’ I believe that in so many situations we’re not giving these young men a second chance. We are giving them their first one. These young men have been failed.” And finally, Duncan captured a fundamental TCOM strengths-based approach when he concluded: “And I believe our young men are the solution, not the problem.”

15th annual TCOM Conference

Culture and Community: Sharing Stories from the Collaborative

TCOM is an approach based on storytelling. People seeking help share their experiences (i.e., tell their stories). Sometimes, parts of their stories are retold by multiple professionals based on their skills and focus. In order to effectively help, these stories must be combined into a single story, and then, common themes from these stories are identified to decide how exactly to help. We do not help based on how people are different but on common themes they share.  

The storytelling aspects of helping do not stop at the client level.   Supervisees tell their stories to their supervisor who should help the supervisees integrate their own story with the stories of the people they serve. Program administrators combine the changing stories of clients across their experience in care to help tell the story of the program. And systems can tell their story by combining all the measured stories across programs, agencies, and communities. Within the international TCOM collaborative, we also share our stories so that others might learn from our experiences.

Culture and community are two almost inseparable factors that have a significant impact on both how our stories unfold and how others can understand us. As the only comprehensive management approach that fully integrates culture into its fabric, the TCOM approach calls on us to be increasingly aware of the role of culture and community in how we decide how to help. The TCOM community is in a unique position to help bring people together while still respecting our differences. This is the theme of the 15th annual TCOM Conference-Culture and Community: Sharing Stories from the Collaborative. This conference will take place in Palm Springs, California on October 2-4, 2019.

Strategies associated with TCOM are now used across the world to create a common language in such diverse places as Italy, Kenya, Hong Kong, and Singapore. This year approximately 80% of all children and youth served by the public sector in the United States will participate in a CANS assessment process. Given this widespread use, it is incumbent upon us to understand, to the best of our abilities the impact of cultural and community factors on the applications of our common language and shared approaches.

Click HERE for full conference details and how to submit your proposal for a presentation!!!

Shelly Paule

Meet Shelly Paule!


Shelly Paule, MSW, LCSW is currently a Policy Analyst with the County of San Diego Health and Human Services Agency, Child Welfare Services. Shelly graduated with her BS in Psychology and her MSW at San Diego State University, completing her final degree in 1998. Shelly has twenty years of experience with Child Welfare Services, including positions as a front line worker, supervisor, manager and now as a Policy Analyst focusing on Mental Health.

Shelly obtained her LCSW in 2004 and began working as a clinician part time. Shelly greatly enjoys using her clinical skills and knowledge as a Field Instructor for multiple undergraduate and graduate programs. She had the pleasure of running an intern unit for two years, completing individual and group supervision. In total, she has provided supervision for 27 interns. In addition, Shelly has provided group and individual supervision for more than 50 LCSW/MFT Candidates. She also trains for the Academy for Professional Excellence, currently focusing on CANS.

Shelly considers the social worker’s role critical to the outcomes that our families experience. Her goal is to support others as they approach and engage families and children in a way that allows us to best meet their needs and build on their strengths in a collaborative and respectful manner. Shelly is proud to be heading up the CANS roll out in San Diego. We are already seeing the positive impact that completing the CANS in the Child and Family Team Meeting is having on the children and families we serve.

You can reach Shelly by emailing her at Shelly.Paule@sdcounty.ca.gov!

Posts written by Shelly Paule

Viva La CANS

By: Shelly Paule, Policy Analyst

County of San Diego Child Welfare Services (CWS)

Hi, my name is Shelly Paule. As a policy analyst with the County of San Diego Child Welfare Services (CWS), I was the lead for managing the Child and Adolescent Needs and Strengths (CANS) implementation. My role included drafting the policy, training roll out and completion, and coordinating with our Behavioral Health Services partners. As a trainer and an advocate for the positive impact CANS will have on the children and families we serve, I also have the privilege of being the face of CANS via road shows.

We started our CANS journey in June 2018 by organizing a committee to discuss potential implementation plans. Who would complete the CANS? How would we know which children and families needed the program? How would we successfully integrate this new assessment into the Child and Family Team (CFT) meeting? How would we help families understand its purpose and how this conversation will come alive in the case plan?

Our committee completed an analysis of these questions and provided some answers to County leadership. Simultaneously, we were invited to participate in the Behavioral Health Services CANS Training for Trainers (T4T), with three of us fortunate enough to be able to attend.

Each of us successfully certified at the .70 level, but hitting the .80 required to become a certified trainer was a bit more challenging! This was a great time for us to pull together, review vignettes and practice using the CANS together. This collaborative effort reflects not only the vision of the CANS completion, but also the heart of CWS and the entire Health And Human Services Agency. We know that together we make better assessments and decisions than we do alone.

At CWS, we have also been working collaboratively with the San Diego County Behavioral Health Services (BHS) CANS team led by Eileen Quinn-O’Malley. Eileen has been a great support since BHS completed the CANS roll out in July to its providers. She has shared successful strategies with us and we are scheduled to co-present at Community Presentations to demonstrate our collaboration as large systems.

The CWS training and implementation roll out is scheduled to occur through spring 2019 with additional trainings to follow. More than 700 staff will be trained and certified by April 2019. The first cohort of training was our Pathways to Well Being Social Workers, who started in October and will complete the intake CANS within the CFT meeting on all new cases. They also will assist with coaching and support as more social workers become trained and certified in the CANS. As we complete the phased training roll out, all staff who are trained and certified will start utilizing the CANS within the CFT meeting prior to every case plan update.

We are also reminding staff that the Voice of the Family is a critical factor in the choice to utilize the CANS in the CFT meeting. Children, youth and families have shared concerns that their voices have not always been heard in the assessment of their families, as well as in the decisions around the case plan services and expectations. As we message to staff about the CANS, we are sharing with them the benefits of collaborative completion of the assessment in the CFT meeting to guide the creation of the case plan. We will increase our collaboration and transparency with families to ensure their voice is heard and becomes part of the case plan. As families assist with the creation of case plans they will be more engaged, which may increase the speed of reunification or permanency to ensure children safely remain home.

When speaking with staff, we remind them there is no item on the CANS we have not historically discussed and addressed in CFT meetings. We are helping staff realize this is not a practice shift, but rather a guide to discussing potential areas of needs for a child or family along with the discussion about how to address those needs, whether services should be referred, or another intervention put into place. We are also sharing that the Strengths section focuses on evidence-based areas of resiliency. The CANS helps to inform the CFT to look at ways to build a strength, which in turns increases resiliency for the child / youth we are serving.

Are we excited about CANS and the positive impact this will have our Families? Yes we are! In fact, we have two mottoes at CWS in San Diego – Viva La CANS and Yes we CANS! That being said, we are also aware this is a big shift in our practice. We are supporting our staff through training, coaching and ongoing implementation discussions. Though they are not always easy, these discussions are essential to the successful engagement of our teams.


For more information regarding CANS implantation in County of San Diego Child Welfare Services, please contact Shelly Paule, Policy Analyst at 858-616-5942.

Deborah Daro

Meet Deborah Daro!


Dr. Deborah Daro, Senior Research Fellow at Chapin Hall, is considered one of the nation’s leading experts in the area of child abuse prevention policy and early home visiting research. Her current work focuses on the unique and pivotal role early intervention programs, such as home visiting programs, can play in strengthening parental capacity across diverse populations, enhancing child development and keeping children safe. Most recently, Dr. Daro’s research and writing have focused on developing reform strategies that embed individualized, targeted prevention efforts within more universal efforts to alter normative standards and community context. Dr. Daro developed and currently chairs the Doris Duke Fellowships for the Promotion of Child Well-Being, funded by the Doris Duke Charitable Trust. In this capacity, she oversees a network of over 100 young scholars from across the country that represents a diverse array of disciplines and research interests. A primary focus of the fellowship is assisting these young scholars in translating their academic research into relevant policy and practice reforms.

Dr. Daro has completed dozens of multi-site evaluations over the past 40 years that have incorporated a range of research designs including both randomized clinical trials and various quasi-experimental designs. More recently, her work has been guided by the growing realization among program evaluators, implementation scientists and policy makers that a new balance is needed between effectiveness and efficacy studies when investing in program research to guide broad scale replication of evidence based program models. She has served on multiple national advisory boards and has received numerous awards for her contribution to the field of child abuse prevention.

Dr. Daro holds a BA in communications from the University of Illinois at Urbana and a Masters in City and Regional Planning and Ph.D. in social welfare from the University of California at Berkeley.

You can reach Dr. Daro by checking out Chapin Hall or by emailing her at ddaro@chapinhall.org!

Posts written by Dr. Deborah Daro

Home Visiting and the FFPSA: Expanding Child Protection Opportunities

By: Deborah Daro, Senior Research Fellow

Chapin Hall at the University of Chicago

The Family First Prevention and Services Act (FFPSA) (Family First) represents an opportunity to bridge the historic gap between interventions to resolve unhealthy parenting practices and behaviors and programs designed to prevent these behaviors from developing. Creating a shared understanding that treatment and prevention are mutually reinforcing would move us closer to an equitable and just balance among the goals of child safety, child development, and parental autonomy. The trick in accomplishing this integrated effort, however, is determining how best to shift Title IV-E funds from foster care reimbursements to supporting direct services to improve parent and child outcomes.

Two factors are central to making this strategy work – selecting the right target populations and investing in those prevention options most likely to successfully reach and serve these target populations.  In discerning which families are the most appropriate recipients for Family First investments, there is an unsolved tension in the legislation between targeting these investments to children who are identified by the child welfare system as “candidates for foster care” versus broadening the access portal to include parents at who have not formally entered the system but are at high risk of mistreating their children. Other populations likely to qualify for these service investments include children in unstable adoption situations and pregnant or parenting foster youth.

The potential role early home visiting services might play within this new Family First system will depend upon how states resolve the target population issue. Not all home visiting programs working with young children are equally beneficial for all families.  The current three evidence-based home visiting models being considered by the Family First Clearinghouse (Healthy Families America, Parents as Teachers and Nurse Family Partnership) are great fits for working with adoptive families in crisis (assuming the child is an infant or toddler) and for pregnant and parenting foster youth. All three of these models are widely available in many states and have established strong track records with young families.  They strengthen parental capacity and enhance child outcomes. Although many of the families served by these models face significant personal and situational challenges, it is less clear these models have as strong a track record engaging and successfully supporting families currently involved in the child welfare system.

There are other evidence-based home visiting models, however, that have deeper experience with child welfare populations including those who have been identified as likely foster care candidates. Three programs – Attachment and Biobehavioral Catch-Up (ABC), Child First, and SafeCare — all have robust evidence of effectiveness in engaging these populations and achieving outcomes.  And all are “evidence based” as defined by the federal Maternal Infant and Child Early Home Visiting (MIECHV) initiative, suggesting a high likelihood of approval under the Family First Clearinghouse selection criteria.  Specific features of these models include:

  • ABC: a 10-session home visiting model designed to enhance parental sensitivity and enhance child attachment security and regulatory capabilities.  It has been successfully offered to foster parents and birth parents for children 0-5. ( www.abcintervention.org)
  • Child First:  a 6-12 month intervention, targeting prenatal women and those with children under the age of five that blends parent guidance and dyadic, psychotherapeutic treatment.  The program targets children with emotional/behavioral or developmental/learning problems and families with multiple challenges. (www.childfirst.org)
  • SafeCare: a parent-skills training program that addresses three key risk factors associated with child maltreatment – parent-child relationships, home safety, and insuring a child’s health. Each topic is addressed in a 6 session module, with all three modules being delivered in 4 to 6 months. The program has been developed for and successfully served families with substantiated cases of maltreatment and other issues placing them at high risk of out-of-home placement. (www.safecare.org)

All three models meet the qualification criteria established by the Children’s Bureau for using Title IV-E dollars: they have been the subject of randomized controlled trials, with the findings well documented in multiple peer review journals; they have demonstrated a history of working with child welfare agencies and child welfare-involved populations; they can be successfully delivered within the recommended 12 month widow; and they offer a strong replication package including manualized operational guidelines, training protocols and supervisory systems. 

Many families reported to the child welfare agencies are rearing their children in conditions fraught with parenting challenges and safety concerns far beyond what any specific parenting program can hope to resolve, regardless of rigor and quality. Removing children from these environments will remain an unavoidable choice in certain instances. That said, the frequency of this outcome can be reduce by the thoughtful adoption of home visiting programs that fit the challenges these families face. The three models described in this post, coupled with the three models currently under review by the clearinghouse, offer child welfare agencies a strong set of options to advance the Family First mission.


For additional information on ABC, Child First and SafeCare see:

Chaffin, M., Hecht, D., Bard, D., Silovsky, J.F., & Beasley, W.H. (2012). A statewide trial of SafeCare home-based services model with parents in child protective services. Pediatrics, 129(3), 509-515.

Crusto, C.A. Lowell, D.I., Paulicin, B., Reynolds, J., Feinn, R., Friedman, S. R., & Kaufman, J. S. (2008). Evaluation of a Wraparound process for children exposed to family violence. Best Practices in Mental Health: An International Journal, 4(1), 1-18.

Dozier, M., & Bernard, K. (2017). Attachment and Biobehavioral Catch-up:  Addressing the needs of infants and toddlers exposed to inadequate or problematic caregiving.  Current Opinion in Psychology, 15, 111-117.

Gershater-Molko, R.M., Lutzker, J.R., & Wesch, D. (2002).  Using recidivism data to evaluate Project SafeCare:  Teaching bonding, safety and healthcare skills to parents. Child Maltreatment, 7(3), 277-285.

Lind, T., Raby, L., & Dozier, M. (2017). Attachment and Biobehavioral Catch-up effects on foster toddler executive functioning: Results of a randomized clinical trial.  Development and Psychopathology, 29, 575-586.

Lowell, D.I., Carter, A.S., Godoy, L., Paulicin, B., & Briggs-Gowan, M.J. (2011). A randomized controlled trial of Child First: A comprehensive, home-based intervention translating research into early childhood practice. Child Development, 82(1), 193-208.

Dan Warner

Meet Dan Warner!


Dr. Warner is a licensed clinical psychologist with extensive background in human services and mental health.  As the executive director of the nonprofit organization Community Data Roundtable, Dr. Warner has helped implement TCOM systems at all levels, from small providers, to managed care entities, and large state-wide projects.  For Dr. Warner, the heart of human service work is human connections.  His trainings focus on the use of TCOM tools and visualizations to increase human connection, empowering whole systems to become engaged, collaborative, and person-centered for the benefit of a flourishing and just society.

Dan has also been a presenter at the TCOM annual conferences since 2012. He also received the Founders award from The Praed Foundation in 2018 for his innovative and collaborative leadership in supporting the use of data to inform decision making in practice and policy.

You can reach Dan by checking out Community Data Roundtable or emailing him at dwarner@communitydataroundtable.org.

Other posts written by Dan Warner

 

Avoid this Fundamental Mistake in TCOM Tool Scoring: confusing anchor definitions, for concrete details

By Dan Warner, Executive Director-Community Data Roundtable

I have seen many hard-working, diligent people fail TCOM certification because they over-focus on anchor definitions, and do not properly understand the item they are rating.  They think that by focusing on the anchor definitions they are being “detail oriented,” but instead they are “missing the forest for the trees.”  The anchor definitions are not the “concrete” part of a TCOM tool.  It is the items themselves that are concrete.  After all, this is the first rule of a communimetric tool: It is an item level tool, and items are chosen because they lead to different action trajectories in the client’s treatment.  Attending to anchor definitions without fully understanding the items in which they are trying to anchor you, all but guarantees you will score the item incorrectly.

This is one of the key ways that TCOM tools are different from similar biopsychosocial assessments, which spend much of their certification processes making sure that the concrete differences between the levels of a “domain” (typically their “items” are actually whole domains) are well understood by people pursuing certification on their tool.  The details of a “domain” are the most concrete part of the tool in those situations (see for instance CAFAS, DLA-20).  In such a situation, being very attentive to the exact nuances of the language of the anchors for each level of a domain-item makes sense, and attending like this helps you pass those certification exams well.  However … it doesn’t really help with treatment planning.  Further, it is not very flexible in accounting for all the diverse ways that needs and strengths can show up on any given item-domain in the world. 

Anyone who has tried to use such tools in practice realizes quickly that many people simply do not fit in well to the anchor definitions of the various levels.  While passing the testing vignettes is easy, because the vignettes for those certification exams are written to exactly fit into the concrete anchors specified in the tool, in the “real world” no one quite looks like what the assessment captures.  Thus, workers find themselves finagling a person into the tool’s limited concrete definitions, cutting off what doesn’t fit, oblonging other things to make them fit better.  It’s a procrustean process done for the service of the tool, instead of designing optimal treatment.

In contrast, TCOM tools focus on items that we all have to do in our work.  These are the concrete parts of the tool.  If it is not relevant for this person: score a 0!  If it is relevant, now the issue is what are we going to do about it?  Here the action levels are essential: are we going to watch this problem (1), put it on the treatment plan (2), or jump on it intensely (3)?  The anchors affiliated in each item for each of these levels are helpful to see what the item is describing, and to help you pick the appropriate action level.  However, those anchors are concrete only in the context of the item and the actions that need to be taken. And frankly, once you understand the item, scoring these levels is usually a pretty straight ahead process.

In conclusion, if you find that you are failing TCOM certifications over and again, have someone quiz you on what the items on the tool you are testing on mean.  You might be misunderstanding several of these items fundamentally.  It is not because you think something is a crisis, while the vignette designers felt the problems were mediocre.  Instead, you are not understanding a sufficient amount of items, that your scoring is simply looking random.  Reign yourself in, slow down – look at what the item is about, and then scoring it well enough will always get you passed certification, and quite frankly – will get you working actively in the field making top quality plans, that also produce helpful, analyzable data.

Extra note: I wrote this blog post a few weeks ago, but was teaching this morning and again saw a hard working person, furiously scrutinizing her CANS manual during her testing vignette.  She was working on an item and saw that the word “willful” appeared as a part of the anchor definition of the level 2 rating, and then was trying to figure out if the child in the vignette had acted willfully or not.  This was an absolute distraction from the question of if this item was actionable or not for the client.  Willful is just a word that helps describe what an actionable need on this item is, but she was getting all distracted by whether or not in this particular vignette, we were seeing a willful problem.  My response? I took the manual from her, and asked her what the item she was looking at is about.  She couldn’t tell me.  So this helped get us back on course.  I didn’t give her back the manual for the rest of the exam, but asked her to ask her friends what items meant if she didn’t know.  She passed the exam with a high reliability!  This is exactly what I am talking about — the anchor defintions were distracting her from actually understanding what needs to get done.  She was too preoccupied with fitting things into the test, and it wasn’t until I refused to allow her to do this, that she could successfully pass the exam.  Hopefully, this little interchange is also going to help her be a better clinician — focusing on the work she needs to do, not the scoring she needs to do.


For additional support and references on training and certification, visit the TCOM Training FAQ page on the blog for tip sheets and blog posts about TCOM and its tools.

Strategic Sustainability Learning Collaborative

The following blog post is written by our friends at Open Minds. Open Minds is a Behavioral Health Market Research and Management Consulting firm based out of Gettysburg, Pennsylvania. They specialize in the health and human service sector to serve individuals with the mission of providing providers and payer organizations the resources and knowledge to best inform their practice. They believe that by helping organizations in the field make better, more informed, decisions, they will have the means necessary to improve services to those individuals with the most chronic complex needs.

Greetings from OPEN MINDS! I want to take a moment to introduce a new executive education opportunity. The Strategic Sustainability Learning Collaborative has been specifically designed for executives of small to medium size provider organizations. This 12-month, web based program provides an affordable method to gain the tools and insights needed for sustainability in today’s changing health and human services environment. Working together with OPEN MINDS Senior Associates, up to 30 executives from across the country will address the following learning objectives:

  • Understand the drivers of current health and behavioral health market change
  • Assess the ever changing needs of consumers and requirements of funders in order to build effective strategy
  • Develop an organizational competency portfolio for your organization and create a plan to address any deficiencies
  • Prepare your organization to effectively respond to environmental changes through scenario-based planning
  • Understand the framework for organizational strategic planning required to achieve continued sustainability

OPEN MINDS recognizes that in the current human services landscape, managed care and alternative payment models are redefining the “optimal” provider organization size, driving M&A and other affiliations, and disrupting the market.

With over 25 years of human services executive leadership experience, I am excited to coordinate this new Learning Collaborative.

Whether you are a current CEO, member of the Executive Team, or a candidate for a future C-Suite role, the OPEN MINDS Strategic Sustainability Learning Collaborative will provide you the skill sets necessary to develop and implement an organizational strategic sustainability plan to re-position your organization in an ever changing external environment. There are only a few slots left! More information and enrollment forms may be found at:
https://www.openminds.com/store/strategic-sustainability-learning-collaborative/
You may also contact me directly at pneitman@openminds.com if you would like to discuss enrollment further. I look forward to working with you and/or members of your executive team in this unique and affordable professional development opportunity.

openmindfoot

How to do a Quality Assessment, TCOM Style

Presented and written by Lynda Killoran (Centerstone), Lynn Steiner (Chapin Hall at the University of Chicago), and Deborah Thomas (Centerstone)

In our work as trainer, supervisor or clinician, we often hear a variation on THIS theme from assessors who were recently trained on a version of the CANS: “It’s SOOOO long and there are too many questions for me to ask. I have no idea how to use this during the assessment process (or, I already know how to do an assessment, so I don’t need anyone to tell me how to do it).” The implementation of a new tool or resource is often perceived by those who are expected to use it as, alternately, overwhelming, stressful, confusing, frustrating, demoralizing, and so on. This is why in October 2018, at the TCOM conference, we took it upon ourselves to see if we could provide an example of how to use the CANS effectively and seamlessly in practice.

The idea was to show how to bring the CANS to life as a process—not a document—and to demonstrate how the key principles are intertwined with the assessment process. We did not introduce a new way to do an assessment, but rather a new way to name and organize the information that is already collected during an assessment.

The way we did this was to use a short video of a mock assessment, breaking it into three sections and actively engaging our audience in identifying which needs and strengths had been identified during each section, and which principles were being used during the assessment. We pointed out that you can learn a great deal of information in 10 minutes without asking much, or with some prompting – no need to go through every item and ask about it. The discussion focused on what actionable needs and what useful strengths were observed, what key components were evident, how this was similar or different from how they currently did an assessment, and how they might use this information to improve their current method of assessing using the CANS. The feedback we received overall was that attendees found this to be a useful resource for them. They identified how it could be used or adapted both in assessment and in training staff on assessment. We hope you will find it helpful too!

To access the materials that we provided attendees – training video, training guide and activity worksheet—please click here:

S44 vid

This post was collaboratively written by

Lynda K. Killoran, MA, LCPC
Clinical Manager, Centerstone of Illinois

Lynn Steiner, MSW
Senior Policy Analyst, Chapin Hall at the University of Chicago

Deborah Thomas, LCSW
Clinical Manager, Centerstone of Illinois

Family Matters

Family Matters: Why finding and engaging extended family and fictive kin is critical to positive outcomes for children in foster care

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Readiness Inventory for Successful Employment

RISEmploy

Each TCOM tool is a combination of items inside of a domain meant to reflect the emerging needs and strengths of its population of use. It is adaptable. One of these adaptations is the “Readiness Inventory for Successful Employment (RISEmploy), also known as the Strengths at Work (SAW), can be implemented as its own tool or included as a module in the Adult Needs and Strengths Assessment (ANSA). This tool focuses on skills and strengths that can ensure success in obtaining and maintaining a job.

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Continuous Quality Improvement-Moving beyond the data dashboard

“Getting beyond the data dashboard means continuously using rigorous data and evidence to answer the questions that will lead to the solutions that will positively impact the children, youth, and families served by our organizations.” -Yolanda Rogers, Chapin Hall at the University of Chicago

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Reflections from the conference-TCOM2018

2018 was a big year for the TCOM Collaborative. Based on your conference feedback from years before, we work tirelessly to make sure YOU get the most out of the event. From planning, to producing, to posting materials after the conference ends, we depend on your voice.

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Wrapping up the 14th Annual TCOM Conference-Evidence and Transformation: Taking Person-Centered Care to Scale

Here’s What Happened

About 300 people gathered at the Drake Hotel in Chicago last week to attend the 14th annual Transformational Collaborative Outcomes Management conference. Person-centered care was the theme of this our conference this year, and we were excited to collaborate with domestic and international participants.

Workshops focused on how to make best use of TCOM tools in practice, implementations, and supervision. Participants learned how to make meaningful use of CANS data, including using it for effective planning and for measuring well-being. This year also featured a learning track on safety culture. Despite the wide range of topics covered, every presentation was connected through the belief that making that people we serve full partners in the process of care is how transformation happens.

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Conference organizers, Katherine Sun and Michelle Fernando, and additional team members produced an agenda that featured presentations from multiple levels of the system. These included a collaborative workshop by Parent Consultant, Jennifer Griffis, and Chapin Hall at the University of Chicago’s Director of Communication, Marrianne McMullen. They collaborated for months leading up to the conference to share their personal stories and work to produce an interactive session for all attendees. We also had the pleasure of inviting Antonella Di Troia and Anna Didoni from Fondazione IRCCS “Ca’Granda” Ospedale Maggiore Policlinico to deliver a key note address and an additional presentation on how the CANS has been adapted to meet the needs of the children they serve.

Scholarships and Learning Opportunities

The Praed Foundation is proud to announce that more than $7,000 was awarded to individuals and parent partners at the conference for travel support, accommodations coverage, and registration discounts.

CONGRATULATIONS!

Congratulations to the following 2018 TCOM Champion Award Recipients!

  • Carroll Schroeder, Executive Director, California Alliance of Children and Family Services: Founders award for his visionary leadership in encouraging providers and systems in California to bring a transformational perspective to their work.
  • Dan Warner, Executive Director, Community Data Roundtable: Agency level award for his innovative and collaborative leadership in supporting the use of data to inform decision making in practice and policy.
  • Tanya Albornoz, Foster Care Program Administrator, and Kyla Clark, In-Home Program Administrator, Dept. of Human Services in Utah: Systems level award for their innovative adoption of communimetric and TCOM principles in the development and implementation of the UFACET in Utah.
  • Janet Hoeke and Jennifer Griffis, Parent Consultants, Youth Empowerment Services Project (ID): Family partner award for their thoughtful and persistent inclusion of parents’ perspectives in the planning and implementation of TCOM in Idaho.
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Special thanks to our Sponsors:

The TCOM Conferences are made possible by the individuals who organize and manage the conference and all of our sponsors. This year 12 separate organizations made the 3-day conference with over 60 different sessions possible. Among these sponsors were Seneca Family of Agencies, Centene Corporation, Okay to Say, Fidelity EHR, Magellan HealthCareCalifornia Alliance of Children and Families, Objective Arts, TenEleven Group, and Community Data Roundtable, all supported critical events at the conference including the poster session, AV needs, and breaks. A special thank you to Chapin Hall at the University of Chicago, eInsight, and Casey Family Programs, as our Partner Level Sponsors at this year’s conference.

Couldn’t make this year’s conference? Click the link below to download materials. Presentations will continue to be uploaded as they are sent our way.

Conference Program and Presentations


Join us next year for our 15th annual TCOM Conference in Palm Springs, CA!

October 2-4, 2019

Copy of SAVE the Date (4)


TCOM 2018 Speaker Spotlight-David Channer

Meet one of your #TCOM2018 Presenters!

Featured in this post: David Channer

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TCOM 2018 Speaker Spotlight-Betty Walton, Gina Doyle & Wendy Harrold

Meet some of your #TCOM2018 Presenters!

Featured in this post: Betty Walton, Gina Doyle, and Wendy Harrold

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TCOM 2018 Speaker Spotlight-Antonella Di Troia

Meet some of your #TCOM2018 Presenters!

Featured in this post: Antonella Di Troia

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TCOM 2018 Speaker Spotlight-Rachel Andrew

Meet one of your #TCOM2018 Presenters!

Featured in this post: Rachel Andrew

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TCOM 2018 Speaker Spotlight-Nate Lubold

Meet one of your #TCOM2018 Presenters!

Featured in this post: Nate Lubold

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Mapping it out with CANS-Y-LAND

Of the TCOM suite of tools, the most widely used tool is the Child and Adolescent Needs and Strengths Assessment (CANS). The CANS is a communimetric measurement tool that utilizes direct feedback from the youth, family & other team members to identify the actionable needs & strengths of the youth & family in developing and informing the treatment plan. While the tool is proven to be successful and helpful to many people, we always want to make sure that clinicians, case workers, and children find the CANS to be engaging and accessible. This desire is what led Lisa, Caitlin, Dan, Vince and Grace to create CANS-Y-LAND.

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TCOM 2018 Speaker Spotlight-Kyla Clark & Tanya Albornoz

Meet some of your #TCOM2018 Presenters!

Featured in this post: Kyla Clark & Tanya Albornoz

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TCOM 2018 Speaker Spotlight- Vida K. Khavar

Meet one of your #TCOM2018 Presenters!

Featured in this post: Vida Khavar

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Vida Khavar is a Licensed Marriage and Family Therapist who has 25 years’ experience in child welfare. Vida began her career as a clinician in various agencies throughout Los Angeles. She developed expertise in all areas of child welfare while striving to bring Permanency to center stage. Vida became a consultant in 2012 and since then, has assisted a multitude of organizations in developing new or enhancing existing child welfare programs. One of Vida’s priority is to transform the platform on which public and private organizations operate by creating a community that embraces collaborations.

Vida served as a master coach and fidelity reviewer for RISE, a $15 million federal initiative which aimed at improving the lives of LGBTQ youth in foster care. She is currently the getREAL CA project director through Family Builders. She has been collaborating with the California Department of Social Services to develop and implement new policies for LGBTQ+ children in child welfare.                                                e: vkhavar@familybuilders.org

Q: What does Person-Centered Care mean to you?
VK: Many of us have entered the field of social work and social justice in order to improve the lives of children and families. It is crucial to remember that each person is their own expert, therefore, as healthcare practitioners, we must focus on developing treatment plans that match our clients’ needs and the way they see themselves. We must remember that each person is at the center of the many identities they represent through their culture, race, religion, socioeconomic background, SOGIE (Sexual orientation, Gender Identity & Expression), mental health etc., therefore we must listen in order to serve them appropriately.

Q. Why should individuals attend this year’s conference/your presentation?
VK: 22.8% of children in out of home care in the United States identify as LGBTQ, and 57% of these youth are youth of color. These numbers are startling. As health care practitioners, it is essential to develop appropriate programs that meet the needs of these children and their families. LGBTQ+ youth are at a higher risk to find themselves involved with child welfare, criminal justice and homelessness because of their sexual orientation, gender identity and expression.

This presentation will address how to implement practices that address the needs, well-being and permanency of LGBTQ and gender expansive children.  The necessity to address every aspect of each child through the intersection of race, culture, ethnicity and SOGIE will be discussed. Finally, the SOGIE portion of the CANS as well as new policies, lessons learned and practical concepts will be presented to initiate and implement child welfare practices that are LGBTQ affirming.

Q: What drew you to attend this year?
VK: The SOGIE portion of the CANS is not yet well known, even though several counties throughout the US are already using it. It is a wonderful assessment that should be used more systematically and I hope to shed some light on it.

Q: What drew you to present on your specific topic? 
VK: I have had the privilege to collaborate with John Lyons and April Fernando from Chapin Hall at the University of Chicago in redesigning the LGBTQ portion of the CANS. It is an important piece of assessment for organizations who seek to get a better understanding of the children and youth entering their programs. The SOGIE piece allows agencies to provide better tailored services toward the needs of the children they serve. It is my goal to highlight the importance of using this tool when assessing all children.


Connect with Vida!

Attend Vida’s presentation at the 14th Annual TCOM Conference on Thursday, 10/4/2018 at 4:00 pm.

Child Welfare Practices for the Well-Being of LGBTQ and Gender Expansive Children and Youth

22.8% of children in out of home care in the United States identify as LGBTQ. Child welfare reforms throughout the country are mandating that all children be affirmed, and respected and their families supported. This presentation will address how to transform your organization in becoming affirming and develop programs that will address the needs, well-being and permanency of LGBTQ and gender non-conforming children and their families. This plenary will also discuss the intersection between race, culture, ethnicity and SOGIE, and the necessity to address every aspect of each child.

A special thanks to our sponsors this year and other individual donors!
The Praed Foundation, Chapin Hall at the University of Chicago, Casey Family Programs, eINSIGHT (eCenter Research), Seneca Family of Agencies, Centene Corporation, Okay to Say (Meadows MHPI), Fidelity EHRMagellan HealthcareCommunity Data Roundtable, California Alliance of Children and Family Services TenEleven Group

TCOM 2018 Speaker Spotlight- Emily Shapiro & Melissa Villegas

Meet some of your #TCOM2018 Presenters!

Featured in this post: Emily B. Shapiro & Melissa Villegas

emily

Emily B. Shapiro is a Quality Improvement Associate at Jewish Child and Family Services (JCFS) located in Chicago, IL. She has experience in qualitative research, project management, and evaluation consulting for nonprofit and philanthropic organizations. She provides direct quality improvement and evaluation support to a K-12+ Therapeutic Day School and programs serving adults and children with disabilities. Emily earned her Masters of Education from the University of Illinois Chicago’s Measurement, Evaluation, Statistics, and Assessment (MESA) program in 2016 and completed her Bachelor’s Degree in Sociology from Loyola University Chicago in 2012. e: EmilyShapiro@jcfs.org

melissa

Melissa Villegas is currently a Quality Improvement Associate at Jewish Child and Family Services (JCFS) located in Chicago, IL. She has over 13 years of social service experience working in direct service and administrative capacities. She has experience in community organizing, program evaluation, educational workshop facilitation, and has provided trainings on assessment tools and research methods. She is a certified trainer in the CANS, ANSA, and FAST assessments. Melissa earned a Master of Social Work degree from the University of Michigan at Ann Arbor with a focus in Social Policy and Evaluation and a specialization in child welfare. e: MelissaVillegas@jcfs.org

Q: What does Person-Centered Care mean to you?
ES: Person-centered care means seeing the individual and family as equal partners and experts in their own care. It is an actively engaging and flexible process that fosters the individual’s ownership over their own care and allows the provider to improve the quality of support.
MV: When I think of person-centered care, I think of an approach where clients are empowered to directly inform and partner in determining their services and the trajectory of their treatment. It is a philosophy where services should not be a ‘one size fits all’ approach, but really honor that each person is different, and care should be individualized to what each client needs.

Q. Why should individuals attend this year’s conference/your presentation?
ES: The conference provides a space to connect with others working within the TCOM framework, to share challenges with others, and celebrate successes in the field. Our presentations will offer an opportunity to share our recent experiences with implementing an education version of the CANS in a Therapeutic Day School setting this past year as well as our longer-term efforts to keep the ANSA “fresh” for both providers and individuals over the past 9 years of implementation.
MV: Attending the TCOM conference provides an opportunity to network, learn from each other, and continue building upon the knowledge of what is considered best practice. Coming from a quality improvement perspective, it provides an opportunity to see what other organizations are doing related to evaluation. It also provides a forum to learn how to continue making the CANS, ANSA, and FAST assessment tools meaningful across all levels of care.

Q: What drew you to attend this year?
ES: This will be my first year attending the TCOM Conference. I’m excited to learn from others and contribute to the larger discussion of taking person-centered care to scale.
MV:  I have attended the CANS conference once before, and I walked away with so many resources and ideas on how to strengthen our systems. I am excited to hear about new innovations in the TCOM field.

Q: Why did you choose to present on this specific topic?
ES: As one of the few organizations to implement an educational version of the CANS in a Therapeutic Day School setting, we want to share our motivations behind implementation and the lessons we’ve learned along the way. We hope that this topic will resonate with other educational programs and multi-service organizations committed to person-centered care for young people and their families.
MV: At JCFS, we utilize the ANSA, CANS, and FAST assessment tools. We have been using the ANSA assessment in our counseling program for 9 years and the CANS is new to our Therapeutic Day School. When reflecting upon our implementation of these assessments, we thought it would be interesting to share lessons learned in implementing these tools in different settings.


Connect with Emily and Melissa!

Attend their presentations at the 14th Annual TCOM Conference on Wednesday, 10/3/2018 from 2:50-3:50 pm and Friday, 10/5/2018 from 10:10-11:10 am.

Creating a Shared Vision in a Therapeutic Day School Setting

During this session we will share a version of the CANS that combines both social-emotional and academic domains implemented in a therapeutic day school setting. CANS was implemented based on staff recommendation to address the limitations of other data sources (e.g., Individualized Educational Program plans, CAFAS, incident reports). The session will also describe how the CANS supports implementation of Collaborative Problem Solving, an approach to resolve behavioral problems in a collaborative, mutually satisfactory manner. This presentation will provide insights for how to use the CANS in conjunction with other school related data sources. Lessons learned and preliminary data analysis from year 1 of CANS implementation in a therapeutic day school setting will be shared.

Keeping It Fresh: 9 Years of ANSA Implementation

JCFS has been implementing the ANSA in its Counseling program since 2009. This session will focus on the ANSA and 9 years of data analysis and implementation. Participants will see an example of how one organization has adapted the ANSA over time to reflect the needs and strengths of the clients served and how the ANSA is used to communicate, assess, organize, and evaluate individual client progress over time. For example, given that our Counseling program often works with the family and not just an individual, it became evident that the family component was missing from the shared vision of our assessment, and the FAST was incorporated into both the CANS and the ANSA. This session will share reflections on implementation and multi-year data analysis. Several key findings will be shared as well as how this information was integrated into our CQI process.

My Introduction to TCOM

Rebekka Schaffer, Project Assistant at Chapin Hall

I joined the TCOM Team here at Chapin Hall at the University of Chicago at the start of July 2018. When I was first introduced to the team, I was worried I wouldn’t even remember what TCOM stood for, let alone understand what they really do. My fears were eased, however, as soon as I began my online training on the Child and Adolescent Needs and Strengths Comprehensive tool (CANS-Comprehensive). I am by no means an expert in this, but I was able to quickly grasp the progression of the online training and its larger implications in practice (even for someone who has no prior training in this area). While there are many important characteristics to TCOM implementations, and the CANS, its accessibility is the most critical. I think that its accessibility allows everyone to participate in and engage with the process of achieving positive life outcomes.

Unlike other measurement tools, the CANS items are customized for each jurisdiction that utilizes it. The ratings for each of these items aren’t arbitrarily assigned scores—they are ratings that translate into actions. These actions rely on the patient’s identified strengths, which can be used to support their needs.

Too often, the only people who understand the jargon behind these tools and measurements, that are meant to serve others, are the very people who created the tools in the first place. What we need, however, is for people involved at every level of care to understand how measurements work in order to achieve the best possible outcome. TCOM isn’t just geared towards researchers in its own community. It aims to create a common language between researchers, clinicians and case workers, and the families we serve. People should not be left out of their own transformation. TCOM presents a collaborative approach that needs everyone involved to participate in it—and makes that participation possible.

I know that I will continue to learn so much more about TCOM and its tools during my time at Chapin Hall, but I’m already encouraged by how much I’ve learned in just this past month. This is due to the structure of TCOM and its goal of making sure that the people we serve remains as a central tenant of why we all do what we do.

This post is written by Rebekka Schaffer, Project Assistant at Chapin Hall at the University of Chicago. Rebekka joins the TCOM team after graduating June 2018 from The University of Chicago with a major in Comparative Human Development and a minor in Human Rights. Her undergraduate research largely focused on trauma-informed approaches in urban schools and communities.

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You can meet Rebekka, along with many other people using the CANS in their work, at this year’s TCOM Conference!

TCOM 2018 Speaker Spotlight- Jen Cardenas

Meet one of your #TCOM2018 Presenters!

Featured in this post: Jen Cardenas

jencardenas

Jen Cardenas is a Licensed Clinical Social Worker and the founder of the Cardenas Consulting Group. She uses her expertise in clinical and operational management to be a critical thought partner, designer, and coach to leaders of behavioral health and child welfare organizations. She brings her no-nonsense, get-things-done approach to help clients through training, quality management, quality assurance, organizational analysis, implementation, and technical assistance on EHR systems. Previously, Jen was the Director for Quality Improvement at Seneca Family of Agencies–one of the largest children’s mental health providers in California. She has 18 years of experience in behavioral healthcare and 13 years of experience implementing and using TCOM tools. e: jen@cardenasgroup.org

Q: What does Person-Centered Care mean to you?
JC: Person centered care is all about honoring the client and family you’re working with. Trust them – they are the expert in their own lives.  By centering the voices of kids and families, we have the ability to achieve a shared vision and facilitate a corrective therapeutic experience.

Q. Why should individuals attend this year’s conference/your presentation?
JC: The TCOM conference is a great opportunity to meet like-minded folks engaging in transformative work across the world. I’ve picked up tips and tricks for clinical practice, systems work and implementation efforts from the conference.  Attending has made me a better clinician, manager and collaborator!

Q: What drew you to attend this year?
JC: It’s always helpful and grounding to reconnect with the broader TCOM Collaborative. Transformative and collaborative practice is hard and implementations are challenging undertakings.  Connecting with those who are doing similar work rejuvenates me and encourages me to keep moving forward.

Q: What drew you to present on your specific topic? 
JC: We’ve been working on the implementation within Alameda County for more than 5 years. So many ups and downs have been experienced in this effort and we hope that folks can learn from our successes and mistakes.


Connect with Jen!

Attend her presentations at the 14th Annual TCOM Conference on Wednesday, 10/3/2018 at 1:00 pm and Thursday, 10/4/2018 at 12:30 pm.

TCOM Provider Collaborative: Coaching for Success

TCOM Provider Collaboratives have been developed in three jurisdictions (Alameda CA, Washington and New York) and are a new model for TCOM implementation support.  These collaboratives use TCOM practices at a system level to inform implementation activities, sustain progress, coach stakeholders and create a targeted portfolio of tools to create transition from CANS/ANSA as a form to TCOM as a practice model. The collaboratives will present attendees with information on the function and purpose of Provider Collaboratives, integration with TCOM principles and the stages of development of a learning collaborative. From the fragile beginning stages of change management and generating buy-in to creating short term wins, coaching for true family and youth engagement and problem solving to developing and sustaining best practices, the collaboratives will guide a discussion highlighting strategies to engage stakeholders, build competency, improve organizational structures and motivate leadership.

Fostering Radical Collaboration: Regional Reflections on CANS implementation

California’s new CANS mandate is widely accepted as an opportunity for a unified strategy to communicate, address and monitor the individual needs of children, youth and families. This presentation will discuss these opportunities through discussion of a regional convening of providers that explored the challenges and promise of implementing the CANS with the proper supports and regional vision.  A summary of the challenges and strategies shared during that day, as well as highlights of local best practices will be shared. Example Tip Sheets and resource links will be provided to attendees for use in their own organizations.

A special thanks to our sponsors this year and other individual donors!
The Praed Foundation, Chapin Hall at the University of Chicago, Casey Family Programs, eINSIGHT (eCenter Research), Seneca Family of Agencies, Centene Corporation, Okay to Say (Meadows MHPI), Fidelity EHRMagellan HealthcareCommunity Data Roundtable, California Alliance of Children and Family Services TenEleven Group

TCOM 2018 Speaker Spotlight- Jen Griffis & Marrianne McMullen

Meet some of your #TCOM2018 Presenters!

Featured in this post: Jen Griffis and Marrianne McMullen

jgriffisheadshot500k

Jennifer Griffis is a Parent Consultant with the YES Project, which aims to empower the mental wellness of children, youth, and their families. She engages with the system transformation in Idaho by serving on workgroups and supporting the development of statewide parent network designed to encourage parent voice within children’s mental health programs. Jennifer also serves on the Idaho Federation of Families for Children’s Mental Health Board of Directors and recently became a Certified Parent Coach. Jennifer draws upon her own experiences as a mother of seven to provide support to parents who are raising children with behavioral health challenges. e: jengriffis@gmail.com

MarrianneMcMullen

Marrianne McMullen is the Director of Communications and Dissemination at Chapin Hall . She is a former journalist and foster parent whose career in communications has centered on social justice and child welfare. Most recently, she served six years in the Obama Administration as the Deputy Assistant Secretary for External Affairs at the Administration for the Children and Families in HHS. She’s also worked for DC Public Schools and for the Service Employees International Union. She and her husband, Jeff Epton, ran an alternative newsweekly in Dayton, Ohio for seven years. Together they’ve helped raise nine children, including six foster children. e: mmcmullen@chapinhall.org

Q: What does Person-Centered Care mean to you?
JG: As a parent, person-centered care means that professionals are considering more than just a diagnosis when they’re treating my child. They’re also looking at environmental and relational challenges that may not be immediately evident. Instead of attempting to simplify a complex mental-health challenge, they take the time to look at each layer of the situation and use all of those pieces to help my family move forward.
MM: I’m fortunate to have former foster daughters who continue to be my family as adults. One of them recently posted a video that really captures person-centered care (Check it out!). Person-centered care is about focusing on the person, and disregarding everything about how a service is typically delivered. Sometimes our systems work with families in ways that can be counter-productive. Person-centered care is productive and responsive to the individual and the family.

Q. Why should individuals attend this year’s conference/your presentation?
JG: The systems that are serving children do not always make it easy for professionals to apply TCOM principles and strategies. Attending TCOM can provide a refreshed perspective for professionals who are working to transform systems for children and families.
MM: The conference is an amazing opportunity to recharge and learn with a community of people dedicated to children and families. At this year’s  conference, I will take time with participants to look at some of the research and practice on persuasion, and consider how these principles can be used to change behavior to provide more responsive services. Do you need to persuade someone to change a behavior or adopt a new behavior? Come to my workshop and you’ll gain a few more tools in your toolbox to help you do that!

Q: What drew you to attend this year?
JG: I attended my first TCOM conference last year. I appreciated the focus on encouraging and empowering parent voice. It’s that focus that is bring me back this year.
MM: I came to last year’s conference and was moved by being with so many people dedicated to practicing human services in the most compassionate, respectful, and effective way possible. I’m excited that this year’s conference will be in Chicago, and proud to be a part of a Chapin Hall team that will be there in force.

Q: Why did you choose to present on this specific topic?
JG: My presentation is the result of spending the past five years advocating for my daughter’s treatment while at the same time advocating for changes in our state’s children’s mental health system. I’ve personally experienced the power of being able to trust your own story, as well as the power found in encouraging systems to trust the stories of other families during the transformation process.
MM: My study and practice of persuasion includes a set of tools that can help those in local and state child welfare systems implement the changes they need to make to improve services. Why do people adopt new behaviors? Why do they resist doing so? How can you accelerate the adoption of innovation? Let’s talk. Let’s figure out what the field of persuasion and the dissemination of innovations has to offer to members of the TCOM Collaborative.


Connect with Jennifer and Marrianne!

Attend their presentation at the 14th Annual TCOM Conference on Wednesday, 10/3/2018 from 1-4pm.

When All You Can Trust is the Story: A Parent’s Perspective on the CANS

Parenting children with emotional and behavioral challenges is a difficult journey that requires interacting with multiple systems, programs, and professionals. During this journey, parents often lose trust in the system. They begin to fear the professionals aren’t listening. They worry that decisions will be made that aren’t in the best interest of their family or their child. This session, presented from a parent perspective, will shed light on these challenges. It will also share how the right tools, like the CANS, can help parents trust their story to speak when they aren’t feeling heard. And finally, participants will learn how one system is providing opportunities for stories from families to positively impact their systems, programs, and processes while also empowering parents to participate in  larger system change.

Building Change: How to Use Tools of Persuasion to Make Positive Change for Families

This workshop will help those in a position of managing change to thoughtfully strategize about how to best communicate with, and persuade, their target audience. The tools that will be introduced in this workshop can be used anywhere. They can be helpful in both internal and external communications. They can be used to both achieve management objectives, and to achieve public communication goals.

The Development of CHISALS

Thanks to recent technological growth, children are receiving cochlear implants earlier than ever before. This advance in technology offers a great benefit to support earlier development of language skills.   While these advancements are exciting, they, of course, create some new challenges for the young patients, their auditory-verbal therapists, and their families. Because of their young age—less than 18 months—it’s hard to track the impact of the implants.   And it is more also challenging for therapists to communicate with, and counsel, parents who want to understand how their child is responding to the implant.

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TCOM 2018 Speaker Spotlight-Dan Dubovsky

Meet one of your #TCOM2018 Presenters!

Featured in this post: Dan Dubovsky

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TCOM 2018 Speaker Spotlight-Mercedes Busby and Angela Pollard

Meet some of your #TCOM2018 Presenters!

Featured in this post: Mercedes Busby and Angela Pollard

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Supporting Caregiver Connections

By: Angela Pollard

Project Assistant, Chapin Hall at the University of Chicago

Trauma and its effects on healthy development has become a bigger part of conversations in helping systems such as child welfare and behavioral health. Too many children experience a variety of potentially traumatic/adverse experiences (ACES), as a result of institutions and systems that often struggle to keep the best interests of children and families in mind.

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Registration is Open! #TCOM2018

Registration is Open!

Each year we look forward to hosting the Annual TCOM Conference because it gives us the opportunity to bring together leaders and innovators in the fields of behavioral health, child welfare, juvenile justice, education, and more. This year’s conference theme is Evidence and Transformation: Taking Person-Centered Care to Scale. Person centered care is a central tenant of the TCOM philosophy—keeping the child/youth, adult, and family at the CENTER of everything we do. If the person is an equal partner in the use of the TCOM tools and the care process, then it is possible to go to scale with the vision of people as equal partners. Join the TCOM Team and over 100 different presenters at The Drake Hotel in Chicago, IL on October 3-5, 2018.

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Partner Spotlight: The Institute for Innovation & Implementation

About the Institute:

The Institute for Innovation and Implementation (The Institute) serves as a training, technical assistance, evaluation, policy, systems design, and finance center for the Maryland Children’s Cabinet and its member agencies, along with multiple other states, localities, and private organizations. The Institute supports state and local governments and organizations to implement effective systems and practices to best meet the needs of children and youth with complex behavioral needs and their families. This support is provided through three primary units within The Institute: Policy and Finance; Technical Assistance & Implementation; and Research & Evaluation. These units work in an integrated fashion to assist governmental and other organizational entities to achieve better outcomes for children, youth, and their families.

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A Substantial Number of Youth Experiencing Homelessness are Pregnant or Parenting

Chapin Hall at the University of Chicago is a research and policy center focused on a mission of improving the well-being of children and youth, families, and their communities. They combine rigorous research methods to generate evidence, while providing implementation support to apply that evidence in the field. In 2015, Chapin Hall launched the Voices of Youth Count (VoYC). VoYC is a national initiative designed to fill gaps in the nation’s knowledge about the scope and scale of youth homelessness.

The following brief is reposted with permission by Chapin Hall. Visit the original post to view the brief and download the one-pager!

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LGBTQ Young Adults Experience Homelessness at More than Twice the Rate of Peers

Chapin Hall at the University of Chicago is a research and policy center focused on a mission of improving the well-being of children and youth, families, and their communities. They combine rigorous research methods to generate evidence, while providing implementation support to apply that evidence in the field. In 2015, Chapin Hall launched the Voices of Youth Count (VoYC). VoYC is a national initiative designed to fill gaps in the nation’s knowledge about the scope and scale of youth homelessness.

The following brief is reposted with permission by Chapin Hall. Visit the original post to view the brief and download the one-pager!

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TCOM Tools (CANS/ANSA) Certified Trainer

The Child and Adolescent Needs and Strengths (CANS) is a tool that is collaboratively completed to measure a child and family’s strengths and needs. Along with the other TCOM Tools (ANSA, FAST, SSIT, and more), they are evidence-based assessments to support decision-making, including level of care and intervention planning, facilitate quality improvement initiatives, and allows for the monitoring of clinical and functional outcomes. As a communication tool, they facilitate the linkage between the assessment process and design of individualized service plans.

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Validating a Behavioral Health Instrument for Adults: Exploratory Factor Analysis-A Brief Summary

Over the last 10 years, behavioral health systems and organizations have increasingly adopted the Adult Needs and Strengths Assessment (ANSA) to support planning, to monitor progress, and for quality improvement initiatives. However, research related to the ANSA remained scarce. This gap was recently been addressed through a publication by Betty Walton, PhD, and Hea-Won Kim, PhD, from the Indiana University School of Social Work “Validating a Behavioral Health Instrument for Adults: Exploratory Factor Analysis”, published online in the Journal of Social Service Research in March 2018, examined the psychometric properties of the ANSA.

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Examining the Effectiveness of Integrated Behavioral and Primary Healthcare Treatment-A Brief Summary

Using subscales of the Adult Needs and Strengths Assessment (ANSA) and an author created Crisis Event measure, holistic client functioning was assessed for persons diagnosed with comorbid serious mental illness (SMI) and primary healthcare diseases. An ex post facto, quasi-experimental, pre- and post-test design was selected to compare the effectiveness of an integrated behavioral and primary healthcare (IBPH) treatment approach to a treatment-as-usual (TAU) approach, across a 12-month treatment period.

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Building a System of Addiction Treatment, One Addiction at a Time

By: Robert Shearer, MD

Doctor, Middle Tennessee Addiction Center

Incorporating TCOM into Addiction Treatment

I discovered the work of Dr Lyons somewhat by accident when I began working with a case management group that belongs to the Tennessee HealthLink program. This program utilizes the Adult Needs and Strengths Assessment. To best communicate with the case workers, I thought I should get certified in ANSA. I used the training videos of the TCOM team and instantly found the utility of the core concepts of Communimetrics and TCOM. These concepts have opened the door to a significant problem I and physicians like me are facing.

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Driving Adult Recovery Forward with the ANSA in the Public Mental Health System, Part 2

by: Ella Jackson, MA, LMFT

Clinical Specialist, Sonoma County Behavioral Health

Continued from Part 1 posted April 5, 2018

I worked with Anna for 4 years. She was the first client I moved out of a state hospital. She transferred to a local locked treatment program, and as I carefully tracked her progress and setbacks, I learned the value of using the language of the ANSA to talk to my program managers and to Anna herself about decisions regarding her care. As I grew in my work with her, I discovered ways to promote hope for adult clients who had been trapped in locked care for years. The ANSA became a precise tool for accurate reporting to my managers, and a way I could encourage a view of clients that reflected who they were now.

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Driving Adult Recovery Forward with the ANSA in the Public Mental Health System, Part 1

by: Ella Jackson, MA, LMFT

Clinical Specialist, Sonoma County Behavioral Health

I have heard people say that a person receiving care in the adult system for years, a person with Schizophrenia and a history of substance abuse, will not get better. It’s a story I have heard told over and over about many of the adults in our system of care. In my first years working in public mental health, a woman (who we will refer to as Anna for this post) was assigned to my caseload who was in a state hospital.  I was told by other case managers and supervisors who had worked with her that she was a client who was known for using too many resources and too much time, that Anna would never be capable of living outside of locked care.

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The Value of Vignettes

Mention a case vignette to anyone who has gone through the certification process for the CANS, ANSA, CAT/CSPI or FAST and you will likely hear groans, and see eye rolls. Very few people are big fans of testing and vignettes are never as clear or easy as a trainee wishes. So, if test vignettes bring up such emotions, why do we still use them for testing?

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The Start of SYNC

Get IN Chicago is a local organization founded in 2013. Their mission is to identify, fund, and rigorously evaluate evidence-based programs that will reduce violence for individuals and communities in Chicago. Their core programs focus on Cognitive Behavioral Therapy (CBT), Mentoring, and Parent Engagement/Leadership. Last year, Get IN Chicago launched a new Strengthening Youth through a Network of Care (SYNC) initiative. The SYNC uses data from the CANS to understand and provide support for Chicago youth at risk of participating in gun violence.

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Submit NOW to Present at TCOM2018

Planning for the 14th Annual TCOM Conference is underway! Hosted by The Praed Foundation and Chapin Hall at the University of Chicago, we invite you to share your work this October in Chicago, IL.

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Safe Systems Improvement Tool

Safe Systems Improvement Tool

Tennessee’s Communimetric Assessment for Understanding Critical Incidents

The 1st annual Safety Culture Summit gave attendees and their larger audience a glimpse of the work being done around safety culture. Along with the tools shared during the poster session at the summit, Michael Cull, Policy Fellow at Chapin Hall at the University of Chicago, and Tiffany Goodpasture, Director of Organizational Culture and Workforce Safety at TN Department of Children’s Services, had the opportunity to locally share the Safe Systems Improvement Tool (SSIT). 

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TN Safety Culture Summit-2018

The first-ever Safety Culture Summit provided an unprecedented opportunity for child welfare leaders to present strategies, tools and tactics that promote safe, reliable and effective care. Held earlier this month in Nashville, TN, the summit also demonstrated what to expect from the growing partnership from Casey Family Programs, Chapin Hall at the University of Chicago, Tennessee Department of Children’s Services, and Vanderbilt University Center of Excellence for Children in State Custody (COE).

For two days, 148 people across 26 agencies and organizations met at Vanderbilt University. The packed agenda featured speakers who created various safety culture resources, and additional work sessions to plan a multi-jurisdiction Quality Improvement Collaborative (QIC) focused on improving team culture. Speakers included Bryan Samuels and Michael Cull from Chapin Hall, Bonnie Hommrich from TN DCS, David Sanders and Zeinab Chahine from Casey Family Programs, and Jerry Hickson, Tim Vogus, and Jon Ebert from Vanderbilt. Visit LeadTeamFirst.org/2018 summit to learn more about the presenters and view their slides.

PRESENTATIONS

Bonnie Hommrich, Commissioner for TN DCS, kicked off the summit with an engaging account of the changes Tennessee has seen in efforts to better serve children in care. Casey Family Programs shared their message of HOPE by emphasizing the evolution of care over the last 50 years and charting a path for the next 50 years. And Bryan Samuels, Executive Director at Chapin Hall, reinforced the CORE of safety culture and how to build a framework based on strong partnerships around experience, collaboration, and rigor.

Bonnie Hommrich, Commissioner, Tennessee Department of Children’s Services

POSTER SESSION

The team poster session was more than a display of past research; it highlighted the vast amount of tools and resources available to all who attended the conference. These tools include:

  • Huddles and Debriefs
  • Safety Culture Check-Ups
  • Spaced Education and Safety Notices
  • Safety Organizing Strategy: SBAR
  • Reducing Team Stress
  • Critical incident Review: Safe Systems Analysis
poster
Jacklyn Anderson and Chuck Arms sharing their poster, “Reducing Team Stress”

Other tools developed and used in Tennessee include the Safe Systems Improvement Tool (SSIT), the TeamFirst ToolKit, and more. Additional resources can be found at www.leadteamfirst.com.  LeadTeamFirst is a community of practitioners, leaders, researchers, and policy-makers who are committed to improving safety and reliability in professional child welfare.

PARTNERS

The first ever TN Safety Culture Summit would not have been possible without the support of the four key partners. These organizations are vital to the work done in safety culture and will continue to be an essential element in the advancements made in child welfare.

Chapin
VU COE
Casey
TN DCS

For more information on this tool and to learn more about the Safety Culture Summit, respond in the comments below or reach out to Michael Cull, mcull@chapinhall.org.

CANS in NY-Establishing the Institute

CANS-NY Technical Assistance Institute: Providing training, coaching, and technical assistance in effective use of the CANS-NY

New York State is using the Child and Adolescent Needs and Strengths (CANS) as the primary eligibility tool for Children’s Health Home access and as an outcomes management tool within this system. In order to support effective use of the CANS-NY by care managers and supervisors, the CANS-NY Institute will provide a system of training, coaching, and technical assistance.

The Institute is supported by the NYS Department of Health and facilitated by Chapin Hall at the University of Chicago. Executive leadership comes from Dr. John Lyons, who is the primary developer of the CANS and who has supported 36 statewide implementations of the tool. Dr. Suzanne Button brings more than 20 years of experience with behavioral health care and social service programming in New York State to her role as Institute Director.

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A collaborative workgroup, consisting of four private organizations with notable experience in training and CANS-NY usage, will provide coaches and training for CANS-NY users/Health Home care managers in their region. 

This collaborative workgroup will be guided and supported by data gathered through the yearly statewide Learning Needs Assessment, which will first be administered this month! This assessment is designed to identify current training and learning needs and supports related to use of the CANS-NY. It will be distributed to agencies across the state that are using the tool. The results of this assessment will be reviewed by the Institute and available to CANS-NY users and key stakeholders through the TCOM site.

The Institute’s training and coaching activities are also informed by an Impact Board , consisting of youth and families with lived experiences of care, as well as key stakeholders from the State Partners of AIDS Institute (AI), the Office of Mental Health (OMH), the Office of Alcoholism and Substance Abuse Services (OASAS), the Office of Children and Family Services (OCFS), and many others. CANS-NY Institute leadership provides monthly email updates to the Impact Board about its progress and findings, and will hold bi-annual meetings to elicit input on emerging learning needs, Institute effectiveness, and consumer perspective on the CANS-NY.

Information about regional coaches, scheduled trainings, and other resources can be found at the Department of Health website.  Additional information, tip sheets, and support for users of the CANS-NY can be found on the TCOM Training site or at TCOM Conversations.

Click here to view the full announcement and learn more about the key partners involved in the institute.

Respond in the comments below to get connected or learn more about the institute!

How TCOM takes Person-Centered Care to Scale

Person-centered care is a strategy of providing health care that views the people using health and social services as equal partners in the entire process of planning, developing and monitoring care to ensure that the care meets their needs.   The idea that health care should be focused on the person is not new.  A considerable number of prior initiatives over the past decades have had a similar focus.  All of them sound appealing.  The very idea that health care should be about anything other than the health care needs of the individual seeking care is unacceptable.

Despite all of our attempts to change language and strategies, decision making about health care is not always centered around the person seeking care.

>Health care providers weigh in on what they think is in the best interest of the people they serve.
>Insurance companies and government funding authorities develop decision rules that are intended to balance the interests of the people served with the larger interests of all citizens or at least government agencies.
>Drug companies try to influence physician recommendations and decision-making.
>And of course, politicians, on both sides of the aisle, representing constituencies with strongly held moral or religious convictions, sometimes insert themselves into the healthcare decision-making process.

Person-centered care offers some hope of being different from the myriad of ‘patient-first’ type strategies that have been espoused in our lifetimes.  There are two reasons for hope.

1. The approach is openly collaborative. Instead of naïve approaches that claim to put the person at the center of care, the person-centered approach explicitly makes them an equal partner.  This collaborative stance is very consistent with what we have learned about managing complex ‘soft’ systems.  Only hierarchical or collaborative solutions are possible in multiple party systems.
2. The rapid development of the information culture allows for the democratization of information, and hence empowered collaboration, in ways that were not previously possible.

But person-centered care will suffer the same fate as many other good ideas unless we figure out a way to actually embed it into the practice of care.   Without a model, without social processes and strategies that place the principles of person-centered care formally into the day-to-day decisions made in the healthcare marketplace, it will simply be another nice idea left in the dustbin of history.

Transformational Collaborative Outcomes Management (TCOM) offers a pathway to take person-centered philosophy to scale. Consider the key decision points in the TCOM model.   In order to take person-centered care to scale it is necessary to ensure that the people seeking care are full partners in each of these key decisions.

DecisionPointsJPEG.JPG

It is easy enough to conceive that exceptional practitioners could engage individuals as equal partners in each of these key decisions. But to ensure that this happens routinely requires the redesign of processes of care at the individual level. Even if you engage in collaborative care at the individual level, those decisions can be over-ridden at different points of the system. Many are familiar with situations where an individual practitioner’s decision with the person they are serving was vetoed by a supervisor or program manager.   In fact, program and agencies policies are often written in a way that simply takes involvement in decision-making away from everyone. Government agencies and insurance companies are well known for either taking away the individual’s involvement in their health care or creating powerful incentives to directly influence this decision making. In an earlier post we have discussed this as a problem between equality and equity.

By creating and communicating a collaboratively-developed vision of the person’s story, TCOM offers the strategy whereby we can ensure that the people served are treated as partners in all decisions that are made.  If the person is an equal partner in the use of a common assessment strategy (e.g. CANS, ANSA, FAST), then the aggregates (combinations) of these assessments can also be considered fully collaborative.  Collaboration at the individual level is often called engagement; at the program level it is often called teaming; and at the system level it is called system integration.    They are all essentially the same process – building a shared understanding of how to act toward a common purpose.  By using collaboratively-created assessment strategies, we can provide people at every level of the system with person-centered information on how well we are identifying and acting on persons’ needs and strengths. Actions taken by persons at every level of the system can be rooted in continuously provided information about persons’ needs and strengths.  That is the essence of TCOM and it is why this strategy offers person-centered care as an effective mechanism to go to scale with its vision of people as equal partners. The essence of TCOM is about keeping people at the center of everything we do together.

This post was drafted by Dr. John S Lyons and Dr. Nathaniel Israel. Comment below to join the conversation and stay tuned for more information on works to take person centered care to scale!

Gender: A salient variable

by: Marrianne McMullen, Director of Communication and Dissemination
Chapin Hall at the University of Chicago

Before last year’s women’s marches across the country, I felt like the country had turned its back on me and my experiences. Then I joined a 250,000-strong march where no back was turned. From the hundreds of blunt and funny signs, to the inspirational speakers and performers, to the presence of thousands of women and men all smiling at each other – everyone was facing toward women’s experiences.

In the year since, that collection of individual motivations has turned into a movement. It’s been a year at looking at hard truths and ugly stories that are driving change in a range of institutions and systems.

At Chapin Hall, we have long looked at the experiences of individuals to identify how systems need to change. We compile evidence so that it can be used to affect policies and practices that improve children’s chances for success. One body of evidence we’ve compiled is that girls face different and often additional challenges than boys.

Chapin Hall staff
Some of the Chapin Hall team at the march in Chicago 1/20/2018

So it was no surprise that many Chapin Hall staff who have contributed to this evidence attended women’s marches across the country last weekend. Once again, I headed to downtown Chicago, where I was joined by many of my colleagues, where we were joined by about 300,000 others.

Those of us who work in child welfare can see every day that discrimination and inequity limits a child’s chances to thrive. The experience of trauma, such as the many stories shared through #metoo, can also derail healthy development.

Here are just a few examples of where Chapin Hall work has shed light on the impact of gender:

  • Dr. Amy Dworsky has led research on pregnant and parenting foster youth and their unique needs and experiences. One finding was that only 44 % of female foster youth who had a child had a high school diploma or GED when they exited the system. Further, each additional child they had reduced the odds of having a high school diploma or GED by 45%.
  • In another recent study, Dr. Fred Wulczyn and his staff found that girls in foster care run away more than boys, and do so at a younger age. This provides the basis for exploring why young girls run away, the risks associated with that and whether services designed to protect girls are as effective as those designed to protect boys.
  • In our Midwest Evaluation of Adult Functioning of Former Foster youth, we found that young women at ages 23 and 24 worked fewer hours per week and were paid significantly less per hour than employed young men.

This and results from many more studies provide an evidence base for social change. At Chapin Hall we are often immersed in specifics of system change–such as how to measure improvement in outcomes in one child welfare system. But the broader agendas espoused at the women’s marches are also connected to this work.

When recording artist Janelle Monae focused on personal strength at the DC march, it’s what we would want any person struggling with trauma to hear.

march michelle

When actress Asia Argento spoke in Rome about removing the veil of shame for rape victims, and when women in Sydney and Melbourne called for reform of sexual assault laws, they were addressing trauma and appropriate systemic and cultural responses to it.

“Continue to embrace the things that make you unique even if it makes others uncomfortable. You are enough,” Monae said.  “And whenever you’re feeling doubt, whenever you want to give up, you must always remember to choose freedom over fear.”

That’s the choice countless women have made this past year. It’s been a year punctuated by headlines and stories preceded by warnings for “sensitive listeners.” This year’s women’s marches moved from a broad collection of individual responses to a movement pushing for change in all of our institutions.

We are facing forward. We are looking at evidence. We are the evidence. And we’re going to use it to help girls rise.

Just a Parent

By Jennifer Griffis, author of “Parenting with Hope” blog series August 2017

 Join us as Jen shares her experience at the 13th annual TCOM Conference in San Antonio, TX this past fall.

As I walked up to the conference registration table, a feeling of inadequacy began tugging at the corners of my mind.

“I don’t belong here.”

 I thought.

“Everyone else has so much more knowledge and experience. I’m just a parent.”

This wasn’t an unfamiliar feeling. I’d felt it at most of our intake appointments and treatment planning meetings for the past six years. It was a nagging thought that what I have to offer isn’t as valuable as what will come from the professionals in the room.

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But this wasn’t just any conference — it was the TCOM conference. Though my practical knowledge of TCOM was limited, I knew that both the CANS and TCOM placed a high value on parent voice. So, despite the worry that I didn’t have enough foundational knowledge to be able to absorb the information being presented, I made the conscious decision to set aside those feelings of inadequacy and embrace all that the next few days had to offer.

As the day progressed I found opportunities to share my voice, my thoughts, and my experiences. I searched for presentations focused on the practical aspects of TCOM and asked questions to help clarify information. In every interaction, my participation as a parent was respected and honored. My experience here BOOSTED my confidence as a parent raising a child with a mental health diagnosis, as a parent who encourages other parents walking this road, and as a parent supporting a system that is undergoing a transformation. TCOM taught me that effective treatment is intertwined with our family’s story. To separate our story from the treatment planning process diminishes the importance of our past and reduces the opportunity for success in the future.

Like many families on this journey, our story is difficult and complex. I often feel like a burden to professionals, so I just “hit the highlights.” My experience at the TCOM conference reminded me of the beauty and importance of our family’s story. It empowered me to share our story without feeling guilty for its complexity or regret for its difficulty.

TCOM taught me that parent voice matters at each level in the system, from the individual treatment planning process, to the implementation of new services, to the review of system data. But it’s not enough for parents to believe that their voice matters. Sometimes, maybe even most of the time, parents have to teach a system that their voice matters. They have to show the value of having parents involved at every level. They have to instruct the system in how to truly hear what parents are saying. And there may be times when they need to actually create the opportunities for parents to speak.

TCOM taught me that system change is challenging and difficulties should be expected. As a parent working to support a system transformation by lending my voice and experience to the process, I am constantly watching for risks that could limit services or unintentionally create barriers for families. I have a deeply personal interest in seeing the system succeed, but I have limited influence on how the transformation actually moves forward. As I listened to stories from other systems, I realized that when it comes to parent voice in system transformation, it’s not critical that we ensure the system gets it right the first time. What is important is that parents are there to help the system try again after experiencing a challenging implementation.

Reflecting on my experience with TCOM, I am grateful for the opportunities provided within the transformation of my own state’s system to empower parents to use their voice and create positive change. While I don’t know if I will ever move away from feeling like I’m “just a parent” when I’m in a room full of professionals, I was reminded that being a parent is always more than enough to bring to the table.

Thank you Jen for sharing your experience at the TCOM Conference. To connect with Jen and learn more about her and her family, comment below!

Chapin Hall at the 2018 Society for Social Work and Research (SSWR) Conference

By: Matt Brenner, Editor and Information Specialist
Chapin Hall at the University of Chicago

More than a dozen Chapin Hall staff members will contribute to presentations at the 2018 annual Society for Social Work and Research (SSWR) conference. The conference, “Achieving Equal Opportunity, Equity, and Justice,” features more than 500 symposia, workshops, roundtables, and paper and poster presentations and will be held January 10-14 in Washington, DC. Information about all presentations can be found in the conference program.

The Voices of Youth Count project will be the focus of one symposium. Research Fellow Amy Dworsky organized the symposium, which presents four papers highlighting findings from a different VoYC component. (For all papers and presentations, names in bold indicate a presenting author.)

  • Characteristics and experiences of homeless and unstably housed youth in 22 counties: Common themes and local variation — Amy Dworsky, Research Fellow; Molly Mayer, Associate Researcher; Elissa Gitlow, Researcher; Matthew Morton, Research Fellow; and Jennifer Matjasko, U.S. Centers for Disease Control and Prevention.
  • Services for runaway and homeless youth in 22 counties: Programs, provider types and gaps in provision — Colleen Schlecht, Researcher and Amy Dworsky, Research Fellow.
  • Critical conditions and tipping points into couch surfing — Susanna Curry, Richman Postdoctoral Fellow and Gina Samuels, School of Social Service Administration.
  • National prevalence and incidence estimates of youth homelessness — Matthew Morton, Research Fellow; Amy Dworsky, Research Fellow; David Schlueter; Susanna Curry, Richman Postdoctoral Fellow; and Jennifer Matjasko, U.S. Centers for Disease Control and Prevention.

Chapin Hall staff will also participate in additional workshops and sessions. Titles of these workshops are below; names in bold indicate a presenting author.

  • Differential impact of wraparound facilitation best practices on youth outcomes: A latent class analysis — Kaela Byers, Researcher.
  • Early pregnancy and parenting among foster youth: A national discussion to inform research, practice, and policy — Amy Dworsky, Research Fellow.
  • Examining equitable decision-making in child welfare: Child vulnerability and family protective factors as predictors of risk assessment — Bridgette Lery, Researcher.
  • It’s about time: Exploring the relationship between time use and outcomes for children and families — Sara Feldman, Senior Researcher; Kerry Price, Researcher; Fred Wulczyn, Senior Research Fellow; Lisa Holmes, University of Loughborough.
  • Opening the black box: Ethically responsible use of big data — Brian Chor, Senior Researcher and Dana Weiner, Policy Fellow.
  • Research on states’ child and family welfare policies and services: Universities’ partnerships with state agencies — Fred Wulczyn, Senior Research Fellow.
  • Screening for early identification of toxic stress among young children: Validation of the Household Strength and Strain Inventory — Kaela Byers, Researcher.

SSWR is dedicated to the advancement of social work research. It works collaboratively with other organizations to improve support for research among social workers.

Contact Matt Brenner, mbrenner@chapinhall.org, for more information on events at Chapin Hall at the University of Chicago or to learn more about the presentations above.

The Holiday Season Requires Self-Care

As we talked about in our last few posts, the holidays are a complicated time.  Strengths, like natural supports and spiritual/religious worldview and community, are evident.  Cultural stressors can be exacerbated.

In addition, individuals who have experienced loss or those who do not have adequate natural supports can experience the holidays as a lonely time.  Many situations might contribute to this experience: the recent loss of a loved one, the end of a significant relationship, or the contraction of one’s circle of friends might precipitate feelings of distress during the holidays.  Individuals facing the holiday season in the shadow of these losses may feel lonely, alone or left out at holiday time.

Even people with family and social connections who love the holiday season sometimes experience significant pressures to do the holidays “right,” celebrate in multiple households, or have frequent demands on limited time. They can feel overwhelmed, sensitive, or feel they don’t measure up. For people going through tough times, and possibly lacking resources (e.g., single mom who can’t afford gifts; a family whose father lost his job and is worried about eviction), the holiday season can be a time of stress as children make demands for expensive gifts and parents may need to choose between paying an electric bill, providing food, or celebrating in the way they’d like.

And so, while the holidays are a time when we can draw from and experience our many strengths, we may also need to practice our self-care skills to manage the complexity of the season. Some examples of self-care, important during the holidays and always, include:

Physical health: It’s easy to get out of self-care routines in the holiday rush, but departing too much from normal habits can have negative consequences for our health and well-being. We will feel better if we try to keep up our activity level, eat right and get enough sleep. It’s OK to eat more food – or more junk food – than we usually eat, slack off on going to the gym, or fill our schedule with parties and events. But try to fit in physical activity when you can: go for a walk after dinner, build a snowman with the kids or friends and have a snowball fight; turn on a fitness class on the TV and participate; sneak off for a yoga session at the gym. Have a glass of wine – or two – at the party, but stick to non-alcoholic drinks at the next one. Try some of Aunt Alice’s mud pie, but cut yourself a tiny slice to taste.

Mental health: Combat feeling alone at the holidays by treating yourself to something – a nap, a massage, a nice meal, a movie, binge-watching a new show, a new sweater. Reach out to others to schedule fun activities like dinner, a seasonal play, ice skating. Recognize that it’s not personal that friends are so busy and they are likely under pressure too! Say “no” to things you don’t want to do and don’t feel guilty. Set limits on the amount of money you spend on gifts, decorations and activities; suggest free or low-cost alternatives. Focus on the things that matter to you. Start a new tradition with friends or family.

Spiritual health: Contribute in some way; give of yourself and focus on others — volunteer at a soup kitchen, as a mentor, serve at a food pantry or rescue shelter. Offer to work on the holiday so that someone who celebrates it gets the day off. Go caroling. Participate in a toy drive or “adopt a child/family” drive. Join family friends to light Kwanza or Hanukah candles.  Go to Christmas Mass. Meditate.

This should be a happy time of year, but if it is not, reach out to family and friends for support.  Also know that, if your stress or sadness feels unmanageable, you can find professional support resources here: https://afsp.org/find-support/resources/

Whatever your celebration or activity of choice is this season, the TCOM team sends our wishes for your health and well-being during this holiday season and in the year ahead.

 

The Holiday Season Can Increase Feelings of Isolation and Cultural Stress

“‘Tis the season,” as they say.  For some, it is the season of celebration and strengths, but for others, the holidays can represent heightened experiences of cultural stress.

In 2015, a controversy about Starbucks’ holiday cups reflected

the cultural tension evident in a season that can be perceived as Christian-centric.  Starbucks routinely changes its coffee cup design each November.  In 2015, the company decided to remove “traditional holiday symbols” in favor of what it called a “more inclusive” blank canvas of red. Protests began immediately, claiming overzealous political correctness along with a general trend toward what people saw as watering down a favored holiday to please people who were offended by the celebration of Christmas.

We live in a multicultural society, but many Americans identify as Christian and Christmas is built into the nation’s fabric.  Christmas Day is a national holiday, and symbols of Christmas appear early and outnumber symbols of other religious and cultural holidays.

For those who celebrate, or simply enjoy the holiday, there is much to love. Brightly colored light displays; Salvation Army Santas stationed on every corner, ringing bells; hot apple cider; gifts under the tree; the scents of pine, peppermint, and cinnamon. It’s a time to give to others who need; a time to reflect on one’s faith. As a country founded on religious freedom, Christians have the right to celebrate their holiday and those who do not celebrate can choose to appreciate the cultural difference or to opt out.

For those whose culture or religion precludes them from celebrating Christmas, and for those who choose, for other reasons, not to engage in the holiday celebrations, the holiday season can exacerbate feelings of isolation rooted in the dominant culture’s symbolism.

To non-Christians and those who choose not to celebrate, Christmas Day is just another day. Closed businesses are an inconvenience; Christmas greetings may be experienced as alienating or insensitive. The holiday season may result in individuals who do not identify with the dominant Christian culture feeling like an outsider.  Inadvertently, the holidays highlight the presence of discrimination and bias, and can increase the experience of cultural stress.

CULTURAL STRESS – This item identifies circumstances in which the youth and family’s cultural identity is met with hostility or other problems within their environment due to differences in attitudes, behavior, or beliefs of others (this includes cultural differences that are causing stress between the youth and their family). Racism, negativity toward sexual orientation, gender identity and expression (SOGIE) and other forms of discrimination would be rated here.
Ratings & Descriptions
0 No current need; no need for action or intervention.
No evidence of stress between the youth’s cultural identity and current living situation.
1 Identified need requires monitoring, watchful waiting, or preventive activities.
Some mild or occasional stress resulting from friction between the youth’s cultural identity and current living situation.
2 Action or intervention is required to ensure that the identified need is addressed; need is interfering with functioning.
Youth is experiencing cultural stress that is causing problems of functioning in at least one life domain.  Youth needs support to learn how to manage culture stress.
3 Problems are dangerous or disabling; requires immediate and/or intensive action.
Youth is experiencing a high level of cultural stress that is making functioning in any life domain difficult under the present circumstances.  Youth needs immediate plan to reduce culture stress.

The presence of stress related to one’s cultural or religious identity has been linked to mental and physical health effects, including changes in sleep and eating habits, difficulties focusing, and heightened symptoms of anxiety. Researchers have also begun to discover the links between cultural stressors and heightened stress hormone levels, which can have a direct impact on an individual’s heart health or the prenatal environment.

Given this potential for stress for those who feel somehow disconnected from the celebration of the Christmas holiday, might we all set a goal of being mindful of our communication and assumptions during this time?

The Holiday Season Reminds Us Of Our Strengths

The day before Thanksgiving, I was in an elevator with a man, who said, “I love Thanksgiving.  It’s the only holiday of the year that no one feels discriminated against or lonely.”  As we continued to talk, he told me that he was Jewish, and that he frequently felt lonely and stressed during the Christmas holidays.  That same day, The New York Times ran an article featuring the powerful perspectives of four Native American writers on the holiday.  As Sherman Alexie, one of the writers, said in that article, for many Native Americans Thanksgiving is a “really sad holiday…that commemorates the beginning of the end for us, the death of a culture.”

“And so,” I remember thinking, “the holiday season is upon us.”  A complicated time for many.  Holidays can represent a time to access one’s informal supports or tap into family strengths.  They also can be a time when the absence of supports, or struggles in family relationships, can seem more apparent and be more acutely experienced.  As John Lyons often says, we must look to the interaction of the individual and the environment to understand strengths, which are characteristics of the individual and/or environment that promote health and well-being.  The traditions and rituals of holidays can create a context highlighting strengths – when individuals and families are able to feel connected to one another or proud of their shared cultural or religious identity. Family, Natural Supports, and Spiritual/Religious observance are strengths, identified in the CANS Core, that may help individuals tap into a sense of community and connection during the holidays.

Family

Family strength is rooted in positive mutually supportive family relationships.  In the spirit of good will, families often leave their petty squabbles behind them and try to enjoy one another’s company around the holidays. Even families that struggle to get along work to develop a bit more tolerance of and acceptance for individual differences that cause family friction. Identifying and using family supports can help harried or lonely individuals get through the hectic holidays –family members might contribute to the cooking of meals, share caregiving responsibilities while visiting or hosting, or coordinate shopping to help reduce the stress felt around this time of year. Family members who have little contact during the year often reach out to one another during important holidays, reminding themselves and each other of the connection and history between them.

Natural Supports

Emotional and practical support from friends, community members, church members, or neighbors can constitute significant strength during stressful times.  For those who are not close to their families geographically or emotionally, the holidays are also a time for a strengthening of natural supports. For example, a friend whose family lives out of town always spends Christmas day with her “Chicago family,” which keeps her connected to the holiday and not celebrating alone. Natural supports are also activated through an increased cultural focus on volunteering during the holiday season, as people give of their time and money to help others.  Even though consumerism has a hold on some holiday practices, many take this time to support friends and their broader community through gift giving or volunteer work.

Spiritual/Religious

The presence of spiritual or religious practices that guide and support individuals and families can be a significant strength.  While many may celebrate Hanukah, Christmas, or Kwanza as secular cultural holidays, with a focus on giving, eating, and coming together, others experience these holidays as a time to celebrate faith and spirituality.  Kwanza celebrates communitarian philosophy, emphasizing identity, community, and unity as an organizing world view.  Hanukah celebrates the transcendence of dark over light, generosity over famine.  Christmas marks the birth of Jesus, and highlights the presence of sacredness and grace among all peoples.  Alongside traditions of gathering and giving are rituals, religious services, and spiritual traditions that highlight coming together as a community and reaffirming purpose, meaning, and connectedness.

***

FAMILY STRENGTHS – This item refers to the presence of a sense of family identity as well as love and communication among family members. Even families who are struggling often have a firm foundation that consists of a positive sense of family and strong underlying love and commitment to each other.  These are the constructs this strength is intended to identify. As with Family Functioning, the definition of family comes from the child/youth’s perspective (i.e., who the child/youth describes as family). If this information is not known, then we recommend a definition of family that includes biological/adoptive relatives and their significant others with whom the child/youth is still in contact.
Ratings & Descriptions
0 Well-developed or centerpiece strength; may be used as a protective factor and a centerpiece of a strength-based plan.
Family has strong relationships and significant family strengths.  This level indicates a family with much love and respect for one another.  There is at least one family member who has a strong loving relationship with the child/youth and is able to provide significant emotional or concrete support.  Child/youth is fully included in family activities.
1 Useful strength is evident but requires some effort to maximize the strength. Strength might be used and built upon in treatment.
Family has some good relationships and good communication. Family members are able to enjoy each other’s company.   There is at least one family member who has a strong, loving relationship with the child/youth and is able to provide limited emotional or concrete support.
2 Strengths have been identified but require significant strength building efforts before they can be effectively utilized as part of a plan.
Family needs some assistance in developing relationships and/or communications. Family members are known, but currently none are able to provide emotional or concrete support.
3 An area in which no current strength is identified; efforts are needed to identify potential strengths.
Family needs significant assistance in developing relationships and communications, or child/youth has no identified family.  Child/youth is not included in normal family activities.

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NATURAL SUPPORTS – Refers to unpaid helpers in the child/youth’s natural environment. These include individuals who provide social support to the target child/youth and family. All family members and paid caregivers are excluded.
Ratings & Descriptions
0 Well-developed or centerpiece strength; may be used as a protective factor and a centerpiece of a strength-based plan.
Child/youth has significant natural supports that contribute to helping support the child/youth’s healthy development.
1 Useful strength is evident but requires some effort to maximize the strength. Strength might be used and built upon in treatment.
Child/youth has identified natural supports that provide some assistance in supporting the child/youth’s healthy development.
2 Strengths have been identified but require significant strength building efforts before they can be effectively utilized as part of a plan.
Child/youth has some identified natural supports however the child/youth is not actively contributing to the child/youth’s healthy development.
3 An area in which no current strength is identified; efforts are needed to identify potential strengths.
Child/youth has no known natural supports (outside of family and paid caregivers).

***

SPIRITUAL/RELIGIOUS – This item refers to the child/youth’s experience of receiving comfort and support from religious or spiritual involvement. This item rates the presence of beliefs that could be useful to the child/youth; however an absence of spiritual/religious beliefs does not represent a need for the family.
Ratings & Descriptions
0 Well-developed or centerpiece strength; may be used as a protective factor and a centerpiece of a strength-based plan.
Child/youth is involved in and receives comfort and support from spiritual and/or religious beliefs, practices and/or community.  Child/youth may be very involved in a religious community or may have strongly held spiritual or religious beliefs that can sustain or comfort the child/youth in difficult times.
1 Useful strength is evident but requires some effort to maximize the strength. Strength might be used and built upon in treatment.
Child/youth is involved in and receives some comfort and/or support from spiritual and/or religious beliefs, practices and/or community.
2 Strengths have been identified but require significant strength building efforts before they can be effectively utilized as part of a plan.
Child/youth has expressed some interest in spiritual or religious belief and practices.
3 An area in which no current strength is identified; efforts are needed to identify potential strengths.
There is no evidence of identified spiritual or religious beliefs, nor does the child/youth show any interest in these pursuits at this time.

Conference Collaboration

by: Evelyn Kintner and Max Kintner, Northern Rivers

The October 2017 TCOM Conference provided an incredible opportunity for Max and I to present with Stephen Shimshock and Yvonne Humenay Roberts from Casey Family Programs. Although first intimidated by our illustrious co-presenters, it took all of 20 minutes over lunch before Max and I quickly formed a bond with Stephen and Yvonne.   Combining our presentations was an easy affair since we shared a common focus on the two individuals in the therapeutic exchange arena: the practitioner who oversees care provision and serves as the representative of the agency in interactions with the family/youth; and the client who should be both a partner in the decision making processes related to their care as well as a recipient of services.  Like Casey Family Programs, our efforts to improve quality of care at Northern Rivers Family of Services (NRFS) revolves around the engagement of practitioners in an open dialogue about data and how analytics can be used to improve one’s practice.  Our combined presentation demonstrated how that might be done for a mid-size organization such as Northern Rivers and a large multi-site organization such as Casey.

How do you implement a Communimetrics based evaluation model in a mid-size organization?

It has been exactly five years ago this month that I was handed some data and asked by Executive Leadership to “See how much you can get out of the CANS as far as analytics.”  Not even 2 years out of ivory towers of academia, I ran the data and produced a highly technical report that fully demonstrated the utility of CANS data for risk profiling and outcome evaluation.  Unfortunately (for me), however, while the report proved the tool was capable of supporting “predictive analytics,” I quickly learned that at the time there was indeed a small audience in Northern Rivers that understood (or cared about) how metrics could inform the provision of care.  Luckily, I had the support of two key individuals: first, the Chief of Quality Management, who as my supervisor, encouraged me to find venues through which to introduce data and analytics to a doubting service provider base; and second, a colleague (and brother) who as one of the doubting practitioners in one of the NRFS affiliates, challenged me to rethink evaluation in terms of its impact on the “practice of child welfare” and its service providers.  It was through the purposive establishment of an open dialogue about TCOM and the role of data with practitioners and programs that progress was made.

So what worked at Northern Rivers?

Although we are still in the implementation phase, there were 3 strategies in retrospect that have proven to be very effective in moving forward a metrics based evaluation agenda at Northern Rivers.  These were/are:

  1. Getting engagement of Executive Management, by creating opportunities to use data to further the agency’s goals. For NRFS, the first chance to demonstrate the utility of a Communimetrics assessment tool came shortly after releasing the  unread technical report when a personnel change opened up an opportunity for performing utilization review (UR), chart auditing, AND retrospective coding of admission records using the CSPI (Childhood Severity of Psychiatric Illness—the parent of the CANS).  The risk profiles that emerged from the retrospective coding piqued curiosity, leading to a request by the ELT to do a full risk assessment of youth admitted to our Office of Mental Health (OMH) Day Treatment and Residential Programs.  There were many benefits derived from the “UR Project,” including the use of the data to support an application for a capital building grant for ER/Hospital diversion that resulted in a grant award of over $4 million in funding.  CANS and FAST data are now commonly used by the ELT members when advocating for the agency with potential donors, regulators, and state policy makers.
  2. Partnering with your Practitioners by giving them the data and guidance/training they need to do their jobs better today—not tomorrow. In retrospect, the most difficult task in implementing a metrics based model of care has been in gaining the consensus of the service provision staff that metrics are a “good thing” that can improve their practice skills—and as a result, improve the quality of care being provided.  For Northern Rivers, the first foray into practitioner conversion was done as a request from a director who wanted coding guidelines related to “masking effects” and “the 30 day rule.”  The response was the development by QM of a technical manual and training curriculum for ensuring fidelity to TCOM principles.  Although sections of the manual/training have been very well received, practitioners tend to see their practice as an “art” not “science,” thus viewing some guidelines as “too impersonal, too intrusive, and too scripted” on how to craft CANS measureable goals using anchor descriptions.  (My brother has coined the term “Paint by Number care” to capture this resistance.)  Recently, however, the aversion to metrics has somewhat subsided as the agency and program staff have become more successful in using assessment data to document client progress and/or advocate its case with regulators/policy makers.    No doubt, it has also helped that New York State is transitioning its Medicaid youth from a fee-for-service model of care into managed care.  Metrics are no longer seen as “optional” by anyone.
  3. Formalizing expectations in an Evaluation Plan that incorporates TCOM principles. To be effective, it is imperative that all levels of staff from direct care workers to executive leadership clearly understand expectations relating to the conduct of assessments and use of data.  If expectations are not integrated into a formal plan, organization drift will occur and CQI efforts stall.  Formalization performs 2 key functions: it clarifies what the agency considers important and makes concrete the framework through which program efforts are evaluated.

Evaluation activities at Northern Rivers hinge around 4 core TCOM constructs:

  1. Fidelity to TCOM principles, measuring the capacity of programs, management, and direct care staff to utilize the CANS to inform care decisions;
  2. Workforce competencies, measuring the proficiency of: i) Workers to assess need and develop goals using the CANS; ii) Supervisors in monitoring fidelity and caseloads; and iii) Management to inform CQI efforts and business decision making;
  3. Compliance & Care Management (i.e., Managed Care Readiness) using the CANS to document medical necessity, manage workloads, and monitor network needs; and
  4. Impact evaluation to assess client, worker, and program outcomes.

As demonstrated in the presentation, NRFS has successfully utilized these core constructs to guide its analytic and program evaluation efforts.

In closing, Max and I wish to thank those that attended the workshop we co-conducted with Stephen and Yvonne.  Relationships and the learning process continue to mature through ongoing collaboration with attendees.  We look forward to next year’s conference in Chicago!

Max Kintner, PhD

HCI Program Coordinator/Bridges to Health

Northeast Parent & Child Society
1580 Columbia Turnpike | Castleton, NY 12033
max.kintner@neparentchild.org

________________________________________

Eve Kintner, MA, MSW/PhD

Director of Performance Management

Northern Rivers Family of Services
60 Academy Road | Albany, NY 12208
evelyn.kintner@northernrivers.org

Missed Opportunities: Youth Homelessness in America

This month, Chapin Hall at the University of Chicago reached an important milestone in their work on runaway and homeless youth. Voices of Youth Count released Missed Opportunities: Youth Homelessness in America, the first in a series of Research-to-Impact briefs on understanding and addressing youth homelessness.

 The first brief — National Estimates — highlights results from a national survey on unaccompanied youth homelessness in America. The study captures youth homelessness broadly, including sleeping on the streets, in shelters, running away, being kicked out, and couch surfing.

Overall, Chapin Hall’s work suggests that as a nation, we are missing opportunities to ensure that all young people can reach their full potential and contribute to stronger communities and economies across the country. In fact, findings show one in 10 young adults ages 18-25, and at least one in 30 adolescents ages 13-17, experience some form of homelessness over the course of a year.

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Bryan Samuels
Executive Director
Chapin Hall at the University of Chicago
www.chapinhall.org
www.voicesofyouthcount.org

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In the months ahead, Chapin Hall will publish additional briefs on topics related to trajectories into homelessness, the interactions of youth homelessness and systems like child welfare, the evidence regarding interventions to address youth homelessness, and experiences faced by specific subgroups of young people. The aim is to continue to expand our understanding of youth experiences with homelessness. All additional briefs will continue to be posted here!

Additionally, both documents mentioned above can be accessed here:

Take a look at the following articles that mention the project.

For more information on the Voices of Youth Count, visit www.ChapinHall.org and www.voicesofyouthcount.org 

Project SAFESPACE, Part 2 of 2

Implementation and Goals

This is Part 2 of the Project SAFESPACE post. 

 

Project SAFESPACE has experienced many successes since its inception.  The child welfare and behavioral health community interact more frequently and acquired a better understanding of each other’s point of view about service provision.  Both communities have a more formal mechanism for communicating and collaborating with one another on a regular basis.  Staff conduct fidelity monitoring with both workers and providers.  Project staff deliver strong training to DCBS staff in conjunction with EKU.  Project staff workers conduct training together with Super Users throughout the state trained by John Lyons to promote fidelity.  Finally, project staff conduct Clinical Consultation with provider agencies in an effort to provide support, answer process questions and complete chart reviews to monitor inter-rater reliability.

Implementation results in challenges along the way as well.  One of the largest challenges centers on capacity building in both the DCBS and provider communities.  Both systems possess a high level of staff turnover.  This creates inconsistency in rapport building and service provision.  Financial limitations impact the time and resources provider agencies can commit to training and certification of staff.  If these agencies have a limited number of CANS certified clinicians, it could delay administration of the CANS to the clients.  Furthermore, we have seen strong compliance with DCBS staff’s completion of the screeners, but providers demonstrate less compliance with CANS completion.  This lessens the value DCBS workers see in in the overall project goal.  Some providers report struggling with getting enough information from DCBS initially, making it harder to complete the Caregiver Needs and Strengths section of the CANS. Finally, providers continue struggling with understanding how to accurately complete the CANS Assessment Report, while DCBS workers have difficulty understanding and utilizing it.  This continuing education issue will be addressed in training.

The funding for this project ends September 30, 2018, so we must focus on creating a sustainable process.  As we prepare to move into the final year of funding, the Project Team must ensure that processes are in place for successful continuation of accomplishments made thus far. The screeners have been integrated into the management information system (SACWIS). DCBS. A web-based application for CANS completion was developed for provider use and transfer of results to DCBS. Concrete plans for integrating the DCBS training into the standing training academy for new workers are in place.  Provider Super Users have been trained who can train additional staff in their agencies build ongoing capacity.  Additional strategies to promote sustainability that need to be put into place include braiding funding to support the provider web-based application, implementing a plan for ongoing monitoring and oversight of the process, and establishing a process for training new trainers across the state as turnover occurs.  As these strategies develop over the next year, Kentucky prepares for continued utilization of the CANS as the standardized assessment tool for kids in DCBS custody and complete integration of collaboration into its daily practice.

For more information on Project SAFESPACE, comment in the box below or contact Dorothy Hickerson, Dorothy.Hickerson@ky.gov

 

Thank you Dorothy for being a part of the TCOM Collaborative! We can’t wait to hear more.

Project SAFESPACE, Part 1 of 2

Background and Project Overview

In 2013, The Children’s Bureau awarded Kentucky a grant to enhance access to behavioral health services for children in the custody of the Department for Community Based Services (DCBS) and placed in out of home care (OOHC).  This grant is a five-year cooperative agreement between the University of Louisville (U of L), DCBS, the Department for Behavioral Health and Developmental and Intellectual Disabilities (DBHDID), Eastern Kentucky University (EKU) and Kentucky Partnerships for Families and Children (KPFC).  Each partnering agency serves a different role in the implementation of Project SAFESPACE.  The grant is led by U of L which also employs project staff and handles the evaluation.  DCBS and DBHDID work in collaboration to support the child welfare staff and the behavioral health providers who complete the screeners and assessments (CANS), respectively.  EKU coordinates the training for child welfare staff, and KPFC maintains the voice of our families and youth at the forefront of the project as we work through implementation.

This project carries the acronym of SAFESPACE, which stands for Screening and Assessment For Enhanced Service Provision to All Children Everyday.  The project contains three primary components.  The first is the administration of a screener by the child welfare staff early in the OOHC case.  This screener serves several purposes within the project.  First, it identifies behavioral health needs quickly within the service population.  In addition, it provides guidance to the worker about who needs to come to the attention of a behavioral health provider in an expedited manner, and offers additional information to inform assessment and treatment decisions.  Finally, the screener serves as an engagement tool for use with caregivers of origin and foster parents.  Early screening is designed to reduce or eliminate delays in connecting children to behavioral health providers in a proactive manner, thereby creating a less reactionary system.

The second part of the project falls to the responsibility of the behavioral health provider.  The provider administers the CANS to children within the first thirty days after receipt of the  DCBS referral.  In addition, these children receive expedient attention by the provider community since the expectation is they receive an appointment within seven days of the referral, similar to the time frame guidelines utilized for hospital discharges.  The CANS supplements and guides the providers’ currently required assessments, serving to capture and organize the information gathered.  The provider completes an assessment update every 90 days to monitor the client’s progress over time.

The final component of the project focuses on collaboration and information sharing between agencies.  The providers complete and submit the CANS Assessment Report to the DCBS worker as a means of communicating strengths and needs identified from the assessment, along with the client’s diagnoses, the recommended treatment and a rationale for their treatment recommendations.  Once the worker receives this, the worker utilizes this information to engage the caregivers further around the need for treatment and how the child’s needs influences his care, and incorporates these recommendations into their case plan for the child and family.  As a result, the child’s System of Care communicates more effectively and efficiently to serve the child’s needs, and allow for effective and streamlined collaboration utilizing a common vision and common language.

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This overview of Project SAFESPACE is provided by Dorothy Hickerson. Part 2 (11/17/2017) of this post will discuss challenges and successes of  implementation along with goals to better serve children, youth, and families in Kentucky.

Resilience Summit 2017

The National Resilience Institute (NRI) hosted its 4th annual international Resilience Summit at the Palmer House Hotel in Chicago from October 16-18, 2017. Keynote speakers included Michelle Gay, Co-Founder of Safe and Sound Schools: A Sandy Hook Initiative; Steve Gross, Founder and Chief Playmaker of the LIfe is Good Kids Foundation; Janet Hilary, CEO of the Floreat Education Trust in London, Dr. George Bonanno, Chair of the Psychology Department at Columbia University; Dr. Stevan Hobfoll, Chair of the Department of Behavioral Sciences at Rush Medical College, representatives from Wounded Warrior Project’s Warrior Care Network and more!

The Summit brought together stakeholders from across the country and globally to share proven tools and strategies, explore innovative solutions, and engage in collaborative human resilience building.

Michele Gay, the co-founder of Safe and Sound Schools, opened the first session on Collaborating for Better Solutions with a recount of December 14, 2012; the day her daughter, Josephine, was killed during the Sandy Hook shooting and the impact of the tragedy on her community. She shared lessons learned around preparation and response to a traumatic event. Gay emphasized the importance of reviewing emergency preparedness plans with the input of emergency responders, professionals, and other community stakeholders. She encouraged everyone in the room to think about the “pillars” of their support system before a loss. For Michele, these were her faith, family, and friends.

The event continued with four more sessions on Leading through Adversity, Putting Resilience Research into Practice, Building Psychosocial Resilience, and Responding after Crisis. Presentations addressed trauma-informed strategies to build childhood resilience, creating a continuum of support for Veterans, caring for caregivers, and creating environments that support cultural awareness and resilience. Each session dedicated time for attendees to ask the Summit faculty questions and collaborate with each other. Attendees also were given time to participate in fun Resilience Challenges and snap photos. Another highlight was being entertained throughout the Summit by internationally award-winning operatic artist, John Cimino.

To learn more about the resources the National Resilience Institute provides visit https://nationalresilienceinstitute.org/learn.

To view the original post, click here.

Make sure to follow @ResilienceInst  for updates and announcements about next year’s summit!

24 and Counting

My son shared his story in the last post. I would like to share parts of this same story from a parent’s perspective. Raising a child with mental illness is not an experience I anticipated I would be adding to my resume. And just like Emily Perl Kingsley’s essay, Welcome to Holland, I found myself perplexed as to how I had planned for Italy and landed in Holland instead. Holland is not Italy and yet, when you look around, you find beautiful tulips and intriguing windmills. Reflecting back, it’s as if we started out in Italy and made our way to Holland learning, growing in acceptance, and appreciating a world we had not expected. I admit that it has been challenging at times.

Twenty-four years ago, we had a beautiful fun-loving son. He was our first and only child. His laughter was contagious and his love of learning was like a sponge. Our move across the country to Idaho left us starting from scratch finding a support system and longing for family and friends. While we were adapting to our new environment and our new home, our little family sought out new connections and support. As Ryan grew, he began reading on his own at the age of two and writing by the age of three. He loved music and playing with other children. Everything seemed “normal”, although he was a bit quirky. He would twirl his hair with his finger, move his fingers in mid-air to written words that he saw on the TV screen or on signs, and he would move his hands to music as if conducting it. What made the latter behavior even more unusual was that the music, at times, was playing in his head… a place that was comforting and sometimes more stimulating than what was going on around him. Because Ryan would blurt out answers in kindergarten without raising his hand, and he seemed to already know what others were learning, we were asked to have him tested for the gifted program. Test results revealed that he was eligible for the gifted program and accommodations were made for him to attend a second grade Language Arts class for part of the day and attend kindergarten the other half. During this same year, the school psychiatrist saw Ryan and diagnosed him with Dysthymia. What?! How can a young boy be depressed! This was difficult to to understand and it sent me researching for how to help him.

The following year, Ryan was accelerated to second grade. On the surface, this was good news; yet, underneath, I needed to know what this meant. I read everything I could about gifted children and what we needed to do for him. I learned about the social and emotional needs of gifted children and how their brains are actually wired differently from the rest of us. I began to feel the stares from other parents, the whispers as I walked by, and a couple of parents asking me why my child had skipped a grade. This was difficult to explain, and I felt judged.

As Ryan stated in his story, his elementary years are mostly a blur. His teacher started to notice peculiar behaviors. For example, he would fall out of his chair and not know how it happened, sit in his chair upside down (later reporting that he needed the stimulation he received from this to stay focused), and step on the teachers feet not realizing it. I had assumed that the educators at his school would know what to do to help him, both academically and with his behaviors. While I was researching how to help my son, the school asked again for him to be tested. This time, they gave Ryan a diagnosis of Non-Verbal Learning Disability (NVLD). Once again, I was left to my own research in order to understand this new diagnosis. NVLD did not seem to fit for me and we had him tested by an outside psychologist. After weeks of testing, Ryan was diagnosed with Tourette’s, OCD and ADHD. We were devastated. How can this be? What does it mean? How can we help him? Who can help? There were so many questions and no place to go for answers. Again, I was compelled to learn everything I could in order to help my son and my research became all-consuming. The schools did not understand him or his needs. Because he is gifted with mental health conditions, Ryan was not challenged enough in school and school itself was a struggle. There was very little new learning in the early years. Ryan was picked on by his peers and he encountered struggles with a principal who saw Ryan as a battle to be won. We changed schools, changed districts, then returned to our home district. There were, indeed, some exceptional teachers, principals and assistant principals along the way. They showed empathy, looked at his strengths, looked for ways to be creative and were flexible. To them, I am ever grateful.

Doctors and mental health professionals could only do so much for him. We learned that the mental health field is not an exact science; it requires a keen ear and skilled professionals, which we were fortunate to encounter a few times, but it took a lot of trial and error to find the right match. Medications were helpful to a point, and side-effects are sometimes worse than the symptoms we were trying to target. It was also difficult, at times, to tell if they were even helping. What made all attempts at help even more challenging is that mental illness masks gifts, and vice-versa. He wasn’t eligible for various programs that may have proven beneficial because he would represent as “normal” or average. We had catastrophic health insurance and paid for every service out of pocket until I started to receive health insurance through my employer a few years ago. As parents, we found a support group for parents of children with Tourette’s. The group was extremely helpful and we found the Tourette Syndrome Association based in NYC. As helpful as these groups were, every day was a challenge and I felt for my son. I cried for my son, for our family and for my marriage. I also got involved as a support group facilitator, worked with the school district at a high-level providing presentations and information, worked with individual families to help them with IEP and 504 meetings, and got involved with NAMI and the the State Department of Education assisting with the writing of a Twice-Exceptional Manual.

When many parents and children were playing sports, going to parties and hanging out with friends and neighbors, we were visiting counselors, occupational therapists, psychiatrists, doctors and psychologists. We also built a life based on his strengths and interests: piano lessons, skiing, hiking, camping, Scouting and taking road trips. we became a close-knit family. In all honesty and hindsight, I would have preferred to stay in the east where there were more services available for our son and my support network of family members. We are very proud of him and his accomplishments (e.g. that he has earned his bachelor’s degree). We continue to have hope, and still worry about the future. I hold much admiration for my son, and I still feel guilt that we couldn’t have done more or done things differently. I have realized that life is full of dichotomies; I can hold opposing feelings at the same time about one thing. Although our journey passed over the Sistine Chapel and the Colosseum, we have come to appreciate the tulips and the windmills of our lives as we continue to advocate for the needs of children and their families.

sarah

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Thank you Stephanie for sharing your experience with the TCOM community. Your willingness to share your story helps others know that they are not alone. There is a large community of people here to support everyone through their own journeys.

 To reach out to Stephanie, use the comment box below. For questions on additional supports and services, use our contact page to get connected.

 

 

Resilience, Recovery, and Hope

My name is Ryan and I would like to share my story of resilience, recovery and hope. As an individual who suffers from Obsessive-Compulsive Disorder, ADHD and Tourette’s, my life has been quite the roller-coaster ride of emotions.

I have been told I was a giggly, happy-go-lucky toddler. I was able to read at the age of two, and I have always loved learning new information. In kindergarten, my teacher did not know what to do with me since I could already read, write and perform simple math calculations. I was tested for my ability level and was permitted to attend a second grade English class in the afternoon after attending kindergarten each morning. The following year I was accelerated to second grade and entered the gifted education program. While showing signs of depression, I was diagnosed with dysthymia and later Tourette’s along with ADHD. Fast forward a couple of years, and I was blessed with a fourth diagnosis: OCD. It is difficult to assess for mental disorders when you are also gifted because the giftedness can mask the symptoms of psychological disorders.

The majority of my K-12 years are a blur to me. I believe my mind has developed a defense mechanism that keeps me from remembering a large part of my childhood experiences because they are too painful to relive. Concentrating on doing homework became nearly impossible due to the amount of tics that would occur. Tics are a part of Tourette’s, and are defined as involuntary muscular or vocal movements that you can’t control. Eye rolling, blinking, jumping jacks and wrist flicking were a few of the tics that not only annoyed me, but also annoyed authority figures and peers at school, who couldn’t understand why I was doing these things.

I was involved in a few school activities, and played sports in during my elementary school days, as well participated in Boy Scouts. I eventually earned my Eagle Scout rank. I have been playing the piano since I was four years old, and was involved with choirs in junior high and high school, so music has always been a way for me to express myself. In high school, I made a couple of close friends I enjoyed hanging out with, but I was mostly a loner. In terms of my disabilities, I saw around 15 different therapists and providers, and tried a number of different medications, in addition to trying pragmatic speech therapy and occupational therapy.

After graduating high school and receiving a few college scholarships, I attended a university in a neighboring state for one semester. Over the course of that semester, I experienced what might be called a mental crisis. I stopped going to classes, stopped eating regularly, stopped taking my prescribed medications, cut off contact with my parents and only slept and browsed the Internet. I had become extremely depressed due to loneliness and contemporary political events, and feeling like college life was not meeting my personal expectations. I became obsessed with completing my own personal “downward spiral,” which might have eventually ended in suicide had it not been for my parents intervening.

Since that crisis point, I have been learning to heal through a variety of different methods. Therapy, medication, my small network of friends, my family, and an overall change in my mindset all contribute to my well-being. I have earned my bachelor’s degree in media production, and although I have held a couple of part-time jobs, I continue to search for steady full-time employment.

Therapy had been a great way for me to share my thoughts and emotions with someone I trust. In many ways, having a reliable, understanding therapist made all the difference in the world. My therapist and I would assess different areas of my life where I might want to improve: organization, time management, maintaining relationships, balancing work and social life, etc. We would discuss goal-setting and how to deal with obsessive thoughts in a productive manner. My therapist has moved on to a different position, and I have decided to take some time off from therapy and spread my wings to use what I have learned. I would love to have a peer specialist who gets what I’ve been through, and can also support me in ways that my therapist, family and friends can’t. This currently isn’t feasible since I have private insurance and in the state in which I reside, peer specialist services can only be accessed through Medicaid. However, I don’t know what I would do without the health insurance I have; I worry sometimes about health insurance in my near future.

Prescribed medication can get a bad rap, but I find that it helps me focus and get through my day without having an episode. My family and friends are all very supportive, and without them, I would not be where I am today. When I am working, I also do and feel better because too much idle time is not good for my OCD thoughts.

More so than is typical, transitioning to adulthood while dealing with mental illness has come with many challenges. I want the responsibilities of being an adult, like living on my own and pursuing my dreams, but sometimes I become frustrated by what I perceive as a lack of understanding by others. For example, I wish my high school counselor and career counselor had been able to advise me toward colleges that provided comprehensive disability accommodations. I wish colleges themselves would have been more understanding and put programs and services in place for students that have mental challenges. On top of education, looking for work can be tough considering I need to determine at what point I should share some of my life’s challenges with my employer.

There was a specific time during and after high school where I wanted so badly to escape from my own skin that I believed the fantasies in my head were a part of reality. Paranoia and fear seemed like a constant shadow, following me everywhere, because I believed the world was slowly coming to an end in some fashion. Feelings of ridicule and abandonment were constant because I had experienced so much bullying and depression regarding my disabilities in years prior. This potpourri of thoughts and feelings led me to eventually experience the episode during my first semester of college that almost ended me. Pulling myself back from that brink was the first step towards recovery.Ryan2

My past struggles and triumphs have taught me a number of lessons, the primary one being: To be open to all of life’s experiences, both its ups and downs. This is the only way to achieve the goals I have set for myself. I have long had dreams of being a full-time musician, as well as a film director. I graduated last year with a B.A. in Communications with an Emphasis in Media Production and a Certificate in Digital Cinema from Boise State University, which is a great accomplishment and a large reason to feel good about how far I have come. That is one of life’s “ups”. Recently, I was diagnosed with diabetes (one of my mood medications was a major contributing factor) and this is another one of life’s “downs” which with I must now contend.

The German philosopher Friedrich Nietzsche once said, “If you gaze long into an abyss, the abyss also gazes back into you.” I have come a long way since my darkest days. I can now stare at the abyss, and even if the abyss stares back, I can acknowledge it, turn … and walk the other way.

Ryan3

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Thank you Ryan for sharing your life with the TCOM community. Your willingness to share your story helps others know that they are not alone. There is a large community of people here to support everyone through their own journeys.

 To reach out to Ryan, use the comment box below. For questions on additional supports and services, use our contact page to get connected.

Stay tuned next week for a post from Ryan’s mom as she shares her experiences!

Wrapping up #TCOM2017

November 2017 Update: Presentations from the conference are now available here!

 

Thank you to those who attended the 13th annual TCOM Conference. It was another great year and YOU are the biggest part of what made this conference a success!

Make sure to fill out your post conference surveys. Your feedback will be used to help plan next year’s conference!

General Conference Survey: https://redcap.uchicago.edu/surveys/?s=T4KPN3TKCL
Individual Session Surveys (repeat to reflect all sessions): https://redcap.uchicago.edu/surveys/?s=WAJRWJNXTM 

All conferences have key note speakers, a variety of presentations, and even good food J, but what makes the TCOM Conference stand out and why should YOU attend again next year? To begin to answer this question, let’s take a look at this year’s conference!

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Our conference attendees came from 31 states/provinces in the United States and Canada. For 306 members of the TCOM Collaborative, San Antonio was home from October 4-6, 2017. From clinicians and psychologists to administrators and program directors, all had the opportunity to listen and engage in a variety of presentations, network with colleagues and friends, and enjoy what the city has to offer. Most notable about this year was the extent of collaboration happening between individuals of various agencies. We had joint sessions and panel discussions that shined a light to various TCOM Implementations and how the theory of Communimetrics is being applied and practiced. These sessions included a collaboration between Casey Family Programs and Northern Rivers and a panel presentation with individuals from Seneca Family of Agencies, Magellan Healthcare, Texas Health and Human Services Commission, and IU School of Social Work. We also held an evening meeting for the Family Focused Treatment Association (FFTA).

Our 66 different presentations began with a record number of attendees for our pre-conference session on Guerilla Reporting and ended with the C12 Certified Trainer Wrap-Up. If you missed any of the presentations offered or were not able to attend, we will be re-posting the conference program with links to the slides. Stay tuned in a couple of weeks for an update to this blog post with all presentations attached!

Congratulations again to this year’s TCOM Champion Award Winners.

  • Nathaniel Israel for his passionate, creative, and enduring commitment to developing and implementing strategies to engage and help children and families.
  • Tim Kelly for his strong commitment to using information about children and families to support ongoing system improvement.
  • Seneca Family of Agencies for their enduring organizational commitment to improving care of children and families through the use of TCOM principles.
  • Barbara Dunn for her longstanding and deep commitment to collaborative efforts to improve the lives of others through the use of common assessment strategies and the resulting data.
  • Julie Bourne and Eileen Chappelle for their instrumental support in the development of the Harris County Prevention CANS.

As the TCOM Collaborative grows, we depend on your support to host the conference. Thank you to all of our sponsors this year!

Sponsor

Last but not least, don’t forget to save the date for the 14th annual TCOM Conference. Have thoughts or suggestions? Join the planning team! Email Katie Sun, ksun@chapinhall.org, with any questions. We hope to see you there!

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Building Bridges and Collaborative Leadership

By: Ken McGill, LMFT

This year’s TCOM Conference in San Antonio, Texas will tackle the theme of Leadership.

“Many of us—if not all of us—are in a period of rapid change, and to successfully manage change requires leadership. However, leadership must take many forms at many levels of a system and often has little to do with formal power and authority. Leadership will be explored in all its manifestations within the collaborative processes and complex systems.”

Reflecting on this theme of leadership within the TCOM collaborative takes me back to my first CANS Conference in 2007, where I attended and presented for the first time. This conference was held in Boston, Massachusetts (the year the Red Sox won the World Series). I recall seeing my very first ‘duck boat’ and meeting some remarkable people.

While in Boston, I presented ‘Increasing Family Involvement with the Use of the CANS Tools.’  I was incredibly nervous, and I feared no one would attend my session. It turned out that attendees were very excited to learn about what New Jersey was doing[i].

From that point forward, I knew that I was in the ‘right spot.’

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I felt a strong duty to learn as much as I could about how others (other trainers, agencies and states) were utilizing these communication tools. That said, I was not aware that many of people I would meet as TCOM colleagues would become valued and dear friends.

Over the next six years, I attended and presented at CANS/TCOM Conferences all over the country. Dr. Lyons and the TCOM Team- are doing amazing work connecting with leaders throughout the United States, Europe and Asia and assisting them to better serve children, youth, young adults, adults, and their families.

The TCOM Framework and Family Systems

Bridging collaborations and building ‘shared visions’ is a crucial part of the TCOM framework. In Communimetrics, Dr. Lyons highlights the design and use of Communimetric tools, which aim to present information to every person involved in the process in an ‘accessible style’ while assisting in the effective measurement with both reliability and validity . Communimetrics increase the overall transparency of the process to all involved. These principles clarify the context or meaning of the information gathered—and shared.[1]

TCOM philosophy, by being integrated into the ‘work’, effectively addresses the needs of those individuals (children, youth, adults) within context of systems (family, school, community and work).

Transformational means that it is focused on the personal change that is the reason for intervention.
Collaborative means that a shared visioning approach is used–not one person’s perspective.
Outcomes means the measures are relevant to decisions about approach or proposed impact of interventions.
Management means that this information is used in all aspects of managing the system from individual family planning to supervision to program and system operations.

Moreover, the TCOM framework generates a ‘shared vision.’ Within this shared vision, the work becomes the focus of all activity.

When someone walks through my office doors, as a marriage and family therapist, they are seeking help to alleviate their pain or suffering. A shared vision—built between us—can help us gain more awareness and understanding, ultimately with the goal of increasing their overall health and wellness.

When creating a shared vision, we are not just focusing on the paperwork, or how often someone is seen, or if all of the slots/beds are filled. While working in collaboration with those we serve, therapy and its many facets are aimed at transformational processes. Within family systems, and considering families as systems,  we therapists/clinicians/administrators can become true conduits in real systems change by managing and sharing data using the TCOM Tools.

Bringing it Together at this Year’s TCOM Conference

My presentation at this year’s conference—Incorporating the CANS Tool from a Therapist’s Perspective:  Use of Technology, CANS and the Genogram— will be an interactive workshop for attendees to delve into TCOM philosophy and to investigate how it can be incorporated into a therapy session. Participants will explore the process of developing an individualized treatment plan, and understand how this process connects to the concepts of ‘transformation’ and increased wellness.

This session is primarily geared towards therapists, clinical supervisors and those working in agencies which incorporate ‘family therapy’ as part of their treatment milieu. Additionally, participants should be CANS Certified in order to gain the full understanding of this intense ‘hands on’ presentation.

My goals in sharing my own TCOM leadership journey are two-fold:

  • To get you interested in attending the TCOM Conference this year and to get you thinking about possibly presenting at a future conference.
  • To let you know that the TCOM Collaborative is more than just a conference. It is about joining something larger than the sum of its parts. It is a mass collaboration, a shared collaborative, and a movement consisting of compassionate, intelligent and creative individuals, all attempting to improve systems and the lives of children, youth and families on this ‘third rock from the sun’.

I truly hope that I have encouraged you to register and attend this year’s TCOM Conference. It will be an exciting three days in San Antonio—see you next week!

[i] At the time, New Jersey was one of the first states to develop and implement a statewide system of care with use of the CANS Tools and Wraparound.

[1] Lyons, John. (2009). Communimetrics. A Communication Theory of Measurement in Human Service Settings.

For more information about this post and how to connect to it’s author, visit the series home page here!

Using the TCOM Tools in Practice

by: Ken McGill, LMFT

I have learned from and collaborated with the TCOM Collaborative for more than ten years. My formal clinical training has been in family systems, specifically in multi-generational family therapy or Bowenian family therapy.[1] A few years back I presented at an event and began to discuss the CANS and other TCOM Tools with family therapists. Several marriage and family therapists (MFTs) continued to contact me regarding the CANS and TCOM and how they can be used as part of the private practice. I shared with them how I incorporate the TCOM tools in my work with children/youth and families in my practice, and I shared how treatment planning has been significantly more successful with their use.
It is my sincere belief that both TCOM and its associated tools should be brought directly to those who are serving in the private sector (e.g. private practice).  TCOM tools are quite simply standards of effective practice.
As I prepared for the 2015 TCOM Conference an idea dawned on me. In fact, I would go so far as to say I had an ‘epiphany’. I was thinking of how to assist therapists and clinicians with truly understanding and utilizing CANS and TCOM.
I began connecting my experiences using CANS and my systemic training as a marriage & family therapist. I was melding my MFT world with my CANS-TCOM world. Suddenly real clarity came upon me: CANS/TCOM and Family Systems became the perfect pair in my framework.
During my education, I began to truly see the world and the people in it through a systems lens. My formal clinical training began with Family Systems. I studied at Seton Hall University back in the early 1990s, with a focus in marriage and family therapy. I read the theoretical work of systems theorists—such as  Virginia Satir, Jay Haley, Salvador Minuchin and Murray Bowen—who offer elegant theories on the development or causes of concerns as well as solutions to allieviate pain and suffering with regards to the human experience.
Later in my career, I first began to frequently use the CANS and TCOM as a practicing Marriage & Family Therapist (being trained and supervised from a Multi-cultural Family or Bowenian Family Therapy perspective). I was working with the individuals and families in my private practice, and school systems often sent me referrals. Often these referrals were families with children identified as having ‘special needs’—and CANS would then immediately assist in the development of partnership with both the parents and youth. Often these families would tell me that by collaborating with them, by defining and monitoring improvements or outcomes, TCOM ‘demystified’ therapy and ‘normalized’ the processes.

How can we bridge these two aligned and practice-improving frameworks to better and more collaboratively address the needs and strengths of the children and families we serve?

First it is important to get a sense of the history and cornerstones of Family Systems thinking.
Then, we will see how this aligns and bridges with the TCOM communicative frameworks.

What is Family Systems Therapy?
*Return to Post 1 for Ken’s Overview of a “system”

The goal of any therapy is to assist in transforming the lives of those we serve. A family’s patterns of behavior influences the individual and therefore may need to be a part of the treatment plan. In marriage and family therapy, the unit of treatment isn’t just the person – even if only a single person is interviewed – it is the set of relationships in which the person is imbedded.

Family therapy is:

  • brief
  • solution-focused
  • specific, with attainable therapeutic goals
  • designed with the “end in mind”
  • often practiced by Marriage and Family Therapists
    (MFTs)[i]

Ken2aFamily Systems Therapy and TCOM

How does all of this background help to bridge the goals of TCOM with family systems therapy?

I view the steps to connecting the work that we do as therapists/clinicians with TCOM and family systems therapy as a perfect continuum:

  • First, we begin to define what it is we are attempting to accomplish.
  • Then, we define the parameters from which are work is to be done.
  • Throughout, we maintain full understanding from everyone’s perspective.

Changing practice with systems thinking is outlined across the Praed Foundation website, not to mention in the many works by Dr. John Lyons:

Child and Adolescent Needs and Strengths (CANS) is an assessment strategy that is designed to be used for decision support and outcomes management. Its primary purpose is to allow a system to remain focused on the shared vision of serving children and families, by representing children at all levels of the system

The ‘system’ in this definition is the ‘child-serving system.’ In order to maintain a shared vision, this child-serving system must partner with the youth and family throughout the process. As a communication tool, The CANS becomes the conduit for getting at this partnership and building a shared vision, as well as outlining necessary steps to meet the goals of treatment.

TCOM is the framework for which this work is being done. Is not this the essence of systems theory? The systems view of an individual—within the context of their family, living within a community, internalizing life through cultural lenses—all this is connected to a larger societal influence (bio-ethno-gender-socio-economic status).

Bridging TCOM and systems frameworks provides us (in the most plural, collaborative, systems sense) with the information needed to effectively do our work.

 —

[1] Kerr, Michael E. “One Family’s Story: A Primer on Bowen Theory.” The Bowen Center for the Study of the Family. 2000. http://www.thebowencenter.org.

[i] Marriage and Family Therapists (MFTs) are mental health professionals trained in psychotherapy and family systems, licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples and family systems. Marriage and Family Therapists broaden the traditional emphasis on the individual to attend to the nature and role of individuals in primary relationship networks such as marriage and the family.  MFTs take a holistic perspective to health care; they are concerned with the overall, long-term well-being of individuals and their families.

About Marriage & Family Therapists. American Association for Marriage and Family Therapy. 2017. http://www.aamft.org/iMIS15/AAMFT/Content/About_AAMFT/About_Marriage_and_Family_Therapists.aspx

 

For more information about this post and how to connect to it’s author, visit the series home page here!

Aligning TCOM and Systems Theory

by: Ken McGill, LMFT

In many ways the CANS, the FAST (the family version of the Communimetrics approach to measurement) and the ANSA align with the foundational definition of a system as outlined by Ludwig von Bertalanffy almost 40 years ago. A system must consist of four distinct components:

  1. Objects: the parts, elements or variables within the system. These may be physical or abstract or both, depending on the nature of the system.
  2. A System of Attributes: the qualities or properties of the system and its objects.
  3. Internal Relationships: objects in a system have internal relationships.
  4. The Environment: a system contains things that affect one another within this environment, forming a larger pattern that is different from any of the parts.

This stems from general systems theory, which dates back to the early 1950s, beginning with the pioneering work by Ludwig von Bertalanffy at the University of Alberta in Edmonton, Canada.[i]

General systems theory, which is often used to inform family-based interventions, relates to the general science of ‘wholeness.’ Wholeness can be utilized for scientific study when there is concern for the ‘organized whole.’ The significance of general systems theory as outlined by von Bertalanffy is a scientific attempt to bridge the gap between probabilities and outcomes and/or theorize the probability concerning the likelihood of subsequent events happening.

This systems theory perspective seems to align with the purposes behind the TCOM tools. Individuals, children/adolescents, or adults can and should be viewed from a systems perspective, especially when using the CANS. The family is something more than simply a collection of individuals, and so are many cultural and systemic environments that people live within. The CANS/ANSA/FAST tools should take this into account.

Fortunately, there are already many points of alignment between systems theory and TCOM tools:

  • In the CANS, the person-in-environment definition of both needs and strengths, as well as the inclusion of the Caregiver section, is aligned with this systems theory perspective.
  • The FAST has a domain generally referred to as the ‘Family Together’ to help tell the story of the family system above and beyond the stories of the individual family members. The FAST also views the person being assessed as a physiological, psychological and socio-cultural-behavioral being living within a larger cultural system and connected to family of origin.
  • Similarly, The ANSA charts the adult needs and strengths within the context of that individual’s family of origin, current family constellation, work and community—all systems.

QUESTIONS TO CONSIDER: When using the CANS and the FAST to chart youth/family needs and strengths, shouldn’t it be done within the systems framework of that individual’s family, school and community?  And when using the ANSA in the diagnosing and treatment of adults, wouldn’t it make sense to utilize systemic theory to assist this process?

part1a.png

 


[i] von Bertalanffy, L. (1968). General System Theory Foundations, Development, Applications. New York, NY: George Braziller, Inc.

General systems theory, as outlined by Von Bertalanffy, aims to:

  • Enable integration in the various natural and social sciences
  • Integrate a general theory of systems
  • Use theory to create exact theory in the non-physical fields of science
  • Develop unifying principles running ‘vertically’ through the universe of the individual sciences, bringing us nearer to the goal of the unity of science
  • Argue for much-needed integration in scientific education

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Principle 6. Time frames for measurement are defined

Principle 6. Time frames for measurement are defined (e.g. 30 days, 24 hours) for relevance of observing change.

by: Dr. John S. Lyons

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Concept: Most existing communimetric tools use a 30-day period to define the relevant time period to describe someone.   The reason for a time frame is to ensure that change can be observed.  The purpose of a communimetric measure is to provide a measurement of a person’s story.   In helping professions, the goal is generally to help someone change that story.   So to be fully functional as a measure, it must be possible to detect important changes in people’s stories.

Background: In the initial applications of the CANS and ANSA this was by far the most controversial characteristic of the measurement approach.    We established a 30-day period for describing people with the original versions of the ANSA (i.e. SPI) and the CANS (i.e. CSPI).  Many people were not happy.  As we began to customize versions, people would argue for 90 days, six months, even one year as the rating period.     What was happening was that these assessments were not always being used to simply document an understanding of a person but were being used to justify service receipt.   In other words, an individual (or child) would have to have high enough needs so that funding agencies would allow clinicians to serve them.   After a series of these debates, I began to realize that the system actually created incentives to describe people to be as high need as possible and keep them sufficiently high need.   This recognition was one of the foundational experiences in the development of TCOM.  The system was not actually designed to help people improve; it was designed to prove that they needed continued help.   To this day, this problem remains one of the most fundamental unintended consequences of managing services rather than transformations.

Proof of Concept:  The CANS is now the most widely used measure for evaluating clinical and functional outcomes in public child serving systems in the United States.    Research has demonstrated that this measurement approach is sensitive to meaningful change (Lyons, Griffin, Jenuwine & Quintana, 2003; Lyons, Woltman, Martinovich & Hancock, 2009; Weiner, Schneider & Lyons, 2009) and is related to the fidelity with which an evidence-based practice is implemented (Effland, Walton & Macintyre, 2011).

This is the last post of the Communimetrics Key Principles series. All key principles are critical to understanding the theory of Communimetrics and all TCOM Tools.
FOR A FULL LOOK INTO THIS SERIES, CLICK HERE TO RETURN TO THE HOME PAGE.

Want to learn more about the 6 key principles and Communimetrics? Attend our 13th Annual TCOM Conference to meet Dr. Lyons and the TCOM Team in person!

Principle 5. The What, not the Why

Principle 5. Items found in the TCOM tools are descriptions and generally do not include attributions of cause.

by: Dr. John S. Lyons

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Concept: We generally describe this principle as “it is about the what, not about the why.”   This means that the focus of most items on a communimetric measure is description.  The items are intended to communicate a common or consensus understanding of the focus of a helping effort.     There are a small number of items that can be found on various communimetric tools that have some etiology (i.e. why) embedded in the logic of the item.  This is done when the concept to be measured cannot be described without an attribution to a cause-effect relationship.   Thus, the Adjustment to Trauma item that can be found on both the ANSA and the CANS implies that a traumatic experience has led to current adjustment difficulties.  There is no way to describe a trauma response without an attribution of a cause-effect relationship.   Other than these rare items, all items are descriptive.   In this way, it doesn’t matter, for instance, why you are not going to work; if you are work age and not working, then you are a ‘3’ on Employment.   Also, children could be rated a ‘2’ on School Behavior because they have ADHD and cannot sit still, OR because they do not want to be in school and are intentionally trying to get themselves kicked out, OR because they are being bullied and the teacher is responding to the child’s response to the bullying, OR because they remind the teacher of someone she did not like last year and she is purposefully triggering the child’s behavior.  It doesn’t matter why the child is having trouble behaving at school; the item only describes that they are.

Background: There are two pathways that led to the inclusion of this characteristic.   The first reason why we included a focus on the descriptive is that we wanted to create a strategy based on consensus.  We learned early on that there is far less contention or disagreement among people if you can keep the focus on describing things.   As soon as you get more than one person in a room, you are likely to have more than one theory of why something is the way it is.   Three psychologists are likely to have three different theories to explain a person’s behavior.    Different cultural groups have different ways of thinking about cause and effect as well.    All cultures recognize the phenomenon we usually describe as depression, but there is enormous variation on the causes of this very common human condition, from biological substrates, to self-talk, to a loss of connection to the land, to a loss of faith.   Trying to jump to the ‘why’ before clearly agreeing on the ‘what’ is less effective in building a consensus.

The second pathway to this characteristic was the work with treatment planning that emerged out of early uses of the CANS in both Canada (Regina) and the San Francisco Bay area.   Generically, treatment planning processes can be considered as following a “What” to “Why” to “How” and then back to “What” process.    What is going on in the life of this person?  Why do we think this is going on?  How are we going to help them change it?   Then returning to the original ‘what’ to determine whether we have been successful in helping them change it.    This process is simultaneously simple and profound..

Proof of Concept:  Using a consensus-based strategy has proven to be possible with this approach.  Most mature implementations report that 98% to 99% of the time a consensus can be agreed upon.   Rarely does one perspective have to be an over-ride because of an inability to agree.  There is emerging research in the collaboration demonstrating that consensus-based assessment is more effective than when no effort is made at consensus (Israel, 2017).  Further, the treatment planning approach developed from both the CANS and ANSA has proven to be quite helpful for people to see the value of these tools in facilitating more effective practice.

An interesting challenge to this treatment planning approach has emerged from evidence-based practices (EBPs).   EBPs have a ‘baked in’ theory of change.   For example, Cognitive Behavioral Therapy (CBT) makes the clear assumption that how you think influences or even determines how you feel and what you do.   There is very limited scientific support that this is uniformly true, but you can’t do CBT without that assumption.    Since schools and training programs increasingly emphasize learning EBPs as the training focus, increasingly, young professionals are entering the job market with limited or no ability to actually formulate an individualized theory of change.    We have to then train them on the job with how to think about cause-and-effect in their work with others because they have been told what the cause-and-effect is based on the EBPs for which they trained.   Since even the most applicable EBPs are recommended for only a small percentage of people who actually seek help, this is quite a limiting workforce challenge.

 

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Want to learn more about the 6 key principles and Communimetrics? Attend our 13th Annual TCOM Conference to meet Dr. Lyons and the TCOM Team in person!

Principle 4. Consider Culture and Development

Principle 4. Consider culture and development of the individual prior to establishing the level of measurement.

by: Dr. John S. Lyons

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Concept: In training we often conceptualize a communimetric measure as a strategy for measuring the person’s (or family’s) story.   The background of communimetrics has more in common with qualitative research methods, like grounded theory, than with more quantitative approaches.   With either qualitative or quantitative methods you end up with a number but the routes to that number can be quite varied.    A major goal in all human serving enterprises is to individualize decisions about care.   However, a competing pressure is to create accountable environments that allow comparisons across people and programs and over time.   To achieve this second goal you must have common metrics.   Communimetrics is designed to find the compromise between these two competing pressures.   The fourth key principle is critical to successfully achieving this compromise.

Background: The two aspects of contextualizing the individual story—culture and development–have separate histories.    The first contextualizing consideration to impact this measurement approach was development.     The key experience that informed this principle was a project evaluating residential treatment that I worked on.  The outcome measures were the CFARS for symptoms and the Ansell-Casey as a functional assessment.   The Ansell-Casey is a sophisticated measure of whether or not youth have achieved mastery of key skills.   This measure is designed from a developmental perspective so there are different relevant skills for different age groups.    This design makes enormous sense.   However, when we were trying to analyze the results, it was a major barrier to have different measures for each age cohort since there was a new set of skills used every two years across adolescent development.    So the question became “How do you recognize that developmental processes impact functioning expectations without needing to have a separate measure for each developmental stage?”     The answer is obvious: understand development first and then decide whether action is necessary.  This is what all good clinicians do as a standard part of treatment planning.

The contextualization of culture occurred in parallel.    In all honesty, as a white, monolingual Midwesterner growing up in the 1960s and ‘70s, I had very limited exposure to multiculturalism.   I remember seeing the BITCH test in graduate school—the Black Intelligence Test to Counteract Honkies.  That was the first time I remember being painfully aware that different people thought about things from different cultural worldviews.    But, I had never even been on an airplane until I had my Ph.D. at 25 years of age.  So I really knew little to nothing regarding the real impact of culture.    And then the world began to change for me.   Perhaps the key personal experience was the work I did with the European Consultation Liaison Workgroup and Frits Huyse, MD, Ph.D. in Amsterdam.    The regular travel and work in Europe and the close relationships I formed with people from very different backgrounds than mine was eye opening for me in recognizing the importance of culture on understanding.    After contextualizing the CANS based on development it was a short journey to realize that the same must be done for culture and for essentially the same reason—finding a balance between individualization and a common framework.    It is this common purpose that leads us to combining these two contextualizing factors into the same key principle.

Proof of Concept:   The mostly widely used communimetric measure, the Child and Adolescent Needs and Strengths (CANS) is used around the world and has been adapted to all age groups and a variety of very different cultural contexts on every continent (except Antarctica).    Despite these broad cultural and developmental differences, published and presented research demonstrates that the approach functions with consistency as a reliable and valid decision support and outcome tool.

 

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Want to learn more about the 6 key principles and Communimetrics? Attend our 13th Annual TCOM Conference to meet Dr. Lyons and the TCOM Team in person!

Principle 3. Describe the Person, NOT the person in care

Principle 3. Describe the need, not the fact, which you are addressing. It is about the person, not the person in care.

by: Dr. John S. Lyons

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Concept:   The only way clinical outcomes can be used across a system of multiple interventions is if the clinical measure is independent of the treatment context.    If the clinical measure is dependent on the treatment context then one can only measure episodes of care, and there are enormous challenges for interpreting clinical outcomes across treatment settings.   For this reason a communimetric measure focuses on decontextualizing any active intervention.

There are a variety of ways to describe this process of deconstructing the impact of a treatment that exists only during the application of the treatment.    For example, we might say that if an intervention is ‘masking’ the presence of a need, you describe the need — not the fact that you can mask it.    Or you look at a person’s status before the application of an intervention, then ask: if the intervention were withdrawn, would that person return to their pre-intervention status?

Here are some examples of interventions that mask needs without necessarily resolving them:

  • Locked detention stops youth from running but does not address runaway behavior.
  • Psychotropic medication has a target symptom and one has to take the medication for the functional implications of that target symptom to be resolved.
  • Having a service provider take a child to school makes sure that the child is in school but does not resolve a school attendance problem.
  • 24 hour suicide watch does not resolve suicidal ideation or intention; it simply prevents a death outcome.

There are many similar examples, but they all have the same basic theme.  To effectively communicate a person’s status in a helping intervention, it is absolutely essential to determine what the status of that person would be like if the help was not being provided.

Background:  The origins of this characteristic come from one of the very first applications of the approach.  The original communimetric measure was called the Severity of Psychiatric Illness (SPI), and it was used to model psychiatric emergency decision making.   Child welfare in Illinois asked me to use the same methodology to model decisions to place youth in residential treatment center (RTC) in support of a community re-investment strategy.   From a series of focus groups with system partners, I created the Childhood Severity of Psychiatric Illness (CSPI).  The idea was to save money on RTCs and re-invest in community based care.  But, a re-investment strategy takes 1-2 years to first save money and then to re-invest in a new interventions.   The State had first tried this by asking RTCs to nominate step down candidates.  Instead of identifying the best candidates for living in the community safely, RTCs tended to say “Don’t take Mary.  Mary is doing great.  You will disrupt Mary’s treatment.”   Instead they were more likely to say “Take Johnny.  We aren’t helping Johnny.  Maybe you could?”   So they identified precisely the wrong youth.   After a tragic death outcome (a stepdown youth murdered his grandparents), the State revisited their strategy and that’s when I got involved.    However, the only way their community re-investment strategy could work was if there were youth in residential treatment at the time that really didn’t need to be there, AND that these youth could be successfully returned to the community without intensive supports already in place (to allow the ramp-up of these community-based interventions using cost savings).

To answer the fundamental question of “Which youth are likely to succeed back in a community setting?” we did a review of more than 300 youth in residential care.    In order to have meaningful results, we had to describe youth based on how they would be WITHOUT the residential intervention.    Reviewers were trained to assess youth’s needs prior to placement and then look for evidence that these needs had actually been eliminated rather than simply addressed in care.     This project had a profound impact on the Illinois system at the time and this was the origin of the third key characteristic of a communimetric measure.

Proof of Concept:    Psychometric measures can be used only for monitoring the outcomes of episodes of care.   This reality is entirely due to this third key characteristic.    Using a measure of how someone is doing in residential treatment to guide a stepdown decision can be completely misleading.   The stepdown decision should be based on a projection of how the individual might be if they were NOT in residential treatment. The CANS has been widely used as a cross systems decision support and outcome monitoring tool.    The ANSA has begun to experience the same type of widespread use with adults.   These two measures are among the only measures of functional status that reasonably can be used across systems to assess comparable outcomes.

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Principle 2. Rating for Action

Principle 2. The level of each item translates into levels of action. The measure must be non-arbitrary; every rating has an immediate meaning and the meaning relevant to future action.

by: Dr. John S. Lyons

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Concept:  Blanton and Jaccard (2006) criticized psychometric measures as arbitrary.[1]  In other words, the numbers do not necessarily have any immediate meaning.  This is a major limitation to practical applications of measures.   For example, it is impossible to know the meaning of a difference of a 60 versus a 50 or a 17 versus a 13 on a psychometric measure.    Norms do not fully solve the problem because they simply convert these arbitrary metrics into percentile ranks which still do not easily translate into use in the field.  What are the implications of the difference between and 80 and a 70 on an IQ test?   Plus, establishing and maintaining norms is difficult and expensive, and in some cases may even be impossible, as norms require the accurate measurement of a population.    Since Communimetric measures are designed to communicate, meaning is fundamental, so arbitrary measurement does not work from this perspective.

The first stage of helping is to understand the person’s (or family’s) circumstances.   Before initiating help this type of discovery phase is critical.  Oftentimes this phase is called assessment.   However, it may also be related to access and engagement.   The output of the process of understanding should be a prioritization based on what can be done to HELP.   Given this recognition of the fundamental structure of helping, Communimetric measures are designed to translate the understanding of the person into a plan to help.    The structure of a Communimetric measure is designed so that it fits in the space between the output of the discovery process and the input of the planning process.

There are many possible action structures for a communimetric measure.  The simplest is a two level model:

  • Act
  • Don’t act

While this two option model is the essence of helping, such a stark distinction can be unsatisfying to professionals and the people they serve who may wish for a more nuanced approach. For this reason, the most commonly used action format is the following:

  • Do not act
  • Watch/prevent/assess
  • Act
  • Act immediately or intensively

This structure both establishes clear action levels and creates an ordinal scale of measurement that reflects escalating action.  These more nuanced scales are useful for program and system level applications of the Communimetric approach.

Many measures also have strength or asset or skill type items that are positive in nature and are used differently in planning processes.  The standard action levels for these items are:

  • Strength/skill fully developed (mastery) and may be central to the planning process
  • Strength/skill immediately useful
  • Possible strength/skill identified but must be developed
  • No strength/skill evident

While the action structures described above are the mostly commonly used among existing Communimetric approaches, they should not be considered exhaustive.   There are actually an enormous variety of different types of action frameworks that might be relevant in different circumstances.

Background:    I first proposed the action levels as an alternative way to think about the Likert type ratings in the original Severity of Psychiatric Illness (SPI) and Childhood Severity of Psychiatric Illness (CSPI).  These measures had four level items that were anchored with an essential structure of:

  • No evidence
  • Mild
  • Moderate
  • Severe

However, since these tools were often used in chart reviews it became difficult for reviewers to come up with consensus understanding of these levels.   To assist in chart review studies, I began training reviewers to consider whether something needed to be done in order to distinguish the mild from the moderate level.    To better distinguish the moderate from the severe level, I suggested people consider whether or not the need was dangerous or disabling.

In the conversion of the CSPI to the CANS in 1999, we met with parents and professionals in Allegheny County, Pennsylvania.   At this two day meeting, the original Child and Adolescent Needs and Strengths (CANS) tool was created.   Walking back from lunch on the first day with the lead family representative, Julie Hladio, I was struck by something she said in passing.   From her perspective she said that the family participants thought the action level way of thinking about the item structure was the single most important aspect of how we were talking about developing the CANS.  She told me that parents and family members were sick and tired of undergoing assessment processes where in the end they had no idea what they were supposed to be working on next with their child.    This conversation was the primary impetus for the action levels moving to the forefront of the item design.  Now the action levels are the cornerstone of the Communimetric theory of measurement.

Proof of Concept:   The use of the action levels — in combination with individual item reliability — has created analytic options that are simply unavailable with other measurement approaches.   Communimetric measures can be effectively mapped into sophisticated treatment planning approaches.  Also, algorithms can be developed to support decision making that divides items into actionable (2 or 3) versus not actionable (1 or 0).    At the time of this writing there are now five independent research groups who have demonstrated the reliability and validity of this approach to decision support using the CANS (for example, see Chor, et al., 2012[2]; Israel, et al., 2015[3]).     This scaling approach also fits very well into machine learning analytics that allow branching logic with decision breaks at meaningful levels of each items[4].

Despite the item level design and the action level structure, it also has proved possible to create traditional psychometric scales using Communimetric items.[5]   These scales can be useful for research and evaluation purposes and systems level outcomes monitoring.

In sum, the action level structure of a Communimetric measure creates a meaningful approach at the person level to effectively support planning and level of care decisions, but simultaneously provides useful information in support of more sophisticated analytics.

FOR A FULL LOOK INTO THIS SERIES, CLICK HERE TO RETURN TO THE HOME PAGE.

If you are interested in the articles cited in this post and others in the series, contact support@TCOMTraining.com.

[1] Blanton, H., & Jaccard, J. (2006). Arbitrary metrics in psychology. American Psychologist,61(1), 27-41. doi:10.1037/0003-066x.61.1.27
[2] Chor, K.H.B., McClelland, G. M., Weiner, D. A., Jordan, N., & Lyons, J. S. (2012). Predicting outcomes of children in residential treatment: A comparison of a decision support algorithm and a multidisciplinary team decision model. Children and Youth Services Review, 34(12), 2345-2352. https://doi.org/10.1016/j.childyouth.2012.08.016
[3] Israel, N., Accomazzo, S., Romney, S., & Zlatevski, D. (2015). Segregated care: Local area tests of distinctiveness and discharge criteria. Residential Treatment for Children & Youth, 32(3), 233-250. https://doi.org/10.1080/0886571x.2015.1108090
[4] Cordell, K., Snowden, L., & Housier, L. (2016).  Patterns and priorities of service need identified through the Child and Adolescent Needs and Strengths (CANS) assessment.  Child and Youth Services Review, 60, 129-135.
[5] Lyons, J.S. (2009).  Communimetrics:  A theory of measurement for human service enterprises.  New York:  Springer.

Principle 1. Item Selection

Principle 1. Each item is selected because it is relevant to the decision-making process. Only relevant information is included.

by: Dr. John S. Lyons

Concept:    A communimetric measure is designed to represent a minimum standard of understanding of a person in their circumstances.   The individual items in this approach are designed to stand alone as independent pieces of information to communicate this understanding.   Therefore, the items are designed to be reliable and valid on their own. For many of the commonly used versions of this approach there is a core set of standard items.  For example, there is a core set of 50 items for the CANS that is recommended for most versions. Additional items are used when relevant to support decision making in different situations.   Items are selected in an effort to define a ‘minimum standard of understanding.’  In other words, items should reflect information relevant to:

  1. Contextualizing a person’s circumstances
  2. Reflecting a key target for an intervention
  3. Reflecting a key outcome of an intervention

Background:   This concept comes from the work of Ken Howard’s group, who could be credited with developing the very first outcomes management approach, eventually called Compass[1].   Previously we approached measurement from a traditional psychometric perspective:  We developed a symptom list to have a measure of symptoms; then we developed a functioning list to create a measure of function, and so on.   Once created, these measures were required to be unchanging.   Further, there was always pressure to make the list of items shorter.

In my book ‘The Measurement and Management of Clinical Outcomes’[2], I stated that clinicians could not be expected to spend more than five minutes completing a measure or they simply wouldn’t do it.    Working from this perspective, it became clear that our current design approach guaranteed that the measurement process was independent of the clinical process.   It was always an add-on.   This lack of integration between the actual work and the documentation of the work added operational burden to clinicians without providing them a perceived value.   At the same time I started working in the Department of Medicine at Northwestern University and became familiar with other communimetric measures.    In these approaches, single items were considered scales in and of themselves.     Those combined experiences led to the idea that modularized measures with different items for different applications might be more acceptable to people who complete them.

Proof of Concept:    There are a number of published studies (and more unpublished) that demonstrate that the individual items of a Communimetric measure are in fact reliable and valid on their own to better support the decision-making process.   The first reliability study was published in 2002 by Anderson, et al.[3]  These findings have been replicated in other countries with different Communimetric measures (e.g. Singapore and Europe).

In addition, the item level information has allowed these measures to be scored flexibly to allow a variety of applications that are simply not feasible with a traditional measure that results in a single score.   For instance, treatment planning applications allow for individual item needs to be allocated as Background Needs (not addressed in the plan but exists to provide context), Treatment Target Needs (i.e., causes of the individual’s current challenges) and Anticipated Outcomes (i.e., effects of the identified causes).   This scoring approach makes Communimetric tools like the CANS and ANSA valuable to clinicians for use in generating personal theories of change.   Alternatively, if the decision is about intensity of care or placement, flexible item scoring can allow for the creation of algorithms to support decision making.  These complex metrics involve patterns of actionable needs that have been shown to support effective decision making (e.g. Chor, et al., 2014).[4]   Finally, it is also possible to generate scale scores that are used for change analyses in a manner identical to applications of psychometric measures (e.g, Lyons, 2009).[5]    Thus the item level construction of a Communimetric measure allows maximum flexibility for using the information in a variety of ways to support different decisions in complex systems.

 

FOR A FULL LOOK INTO THIS SERIES, CLICK HERE TO RETURN TO THE HOME PAGE.

[1] Sperry, L., Brill, P. L., Howard, K. I., & Grissom, G. R. (2013). Treatment Outcomes in Psychotherapy and Psychiatric Interventions (Vol. 6). NewYork: Brunner/Mazel.
[2] Lyons, J. S., Howard, K. I., O’Mahoney, M. T., & Lish, J. D. (1997). The Measurement & management of clinical outcomes in mental health. New York: J. Wiley.
[3] Anderson, R.L., Lyons, J.S., Giles, D.M., Price, J.A., & Estes, G.  (2002). Examining the reliability of the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH) Scale from two perspectives: A comparison of clinician and researcher ratings.  Journal of Child and Family Studies, 12, 279-289.
[4] Chor, K. H. B., McClelland, G. M., Weiner, D. A., Jordan, N. & Lyons, J. S. (2014). Out-of-home placement decision-making and outcomes in child welfare: a longitudinal study. Administration and Policy in Mental Health, https://doi.org/ 10.1007/s10488-014-0545-5
[5] Lyons, J.S. (2009).  Communimetrics:  A theory of measurement for human service enterprises.  New York:  Springer.

WISe Symposium

In late July Nate and Danijela headed to Yakima, Washington for the Wrap with Intensive Services (WISe) Symposium.  The WISe Symposium:  Networking to Build Strenghts was hosted by the State of Washington Department of Social and Health Services.  It was the state’s first coordinated event that brought together WISe stakeholders from across the state.  Over the past few years, our team has been working to support the use of CANS and TCOM in the statewide implementation of WISe, and had the honor of being invited to present on the CANS in WISe.

Yakima.jpg

Their presentation, CANS in WISe: Empowering Youth and Family Voices, was an interactive presentation that walked through 3 applications of the CANS to working together with families and youth in WISe.

  1. Using the CANS to organize family and youth stories to amplify family and youth voice.
  2. Using CANS ratings for individualized planning-a full walk through.
  3. Using profiles of CANS ratings to identify and grow sustainable success in the community.

To view their powerpoint presentation, click here!
 

For more information on this presentation and the work being done in Washington, contact Nathaniel Israel, nisrael@chapinhall.org, or Danijela Zlatevski, dzlatevski@praedfoundation.org
SEE BELOW FOR A SUMMARY OF THEIR SESSION

Session 1 Summary

Number of Attendees:  26

Attendees Post-Session Intentions to Use Data:
Nope Probably Not Probably So For Sure
0% 0% 57% 35%

Eight percent of respondents hand-wrote that they were unsure of whether or not they would use the CANS data post-session.

Session 1 Follow-up Requests

Eighty-five percent of persons attending requested some type of follow-up.

  • 40% of requests were for support around accessing data and/or running reports
  • 52% of requests had to do with needing training on using the CANS in daily practice with families or daily work routines
  • 8% of requests centered around improving the online or reliability training available

Session 2 Summary

Number of Attendees:  11

Attendees Post-Session Intentions to Use Data:
Nope Probably Not Probably So For Sure
0% 9% 55% 36%
Session 2 Follow-up Requests

Seventy-three percent of persons attending requested some type of follow-up.

  • 33% of requests were for support around accessing data, running reports, or using information from reports
  • 56% of requests had to do with needing training or supports for using the CANS in Wraparound / treatment practice. There was more emphasis in these comments on building understanding across providers in different levels of care (such as CLIP) and other child-serving systems (such as Juvenile Justice).
  • One comment simply indicated that the information was helpful for the person’s role as a contract manager and that no immediate follow-up was needed.

Advocating for the Appropriate Level of Care

Parenting with hope through the hard places by Jennifer Griffis.
Visit the homepage for the full series!

I drove 70 miles to attend this meeting in person. My husband adjusted his work schedule so he could call into the meeting, and my mother-in-law was in the waiting room of the office entertaining a couple of our other kiddos who had traveled with me.

We’d been given the impression that today’s treatment team meeting was simply a formality, the final step in approving funding for services which other professionals had already determined our daughter needed. But as the chairs around the table began to fill with clinicians and administrators I began to feel uncomfortable…and outnumbered.

“We’ve reviewed the request for residential care and it doesn’t meet our qualifications for least restrictive environment. We have to see how your daughter does in a lower level placement first. We can offer you a therapeutic foster placement, but not residential.”

I sat there in stunned silence. This was not what I’d expected. Our clinician had been so supportive. She knew our story, our parenting, our family. She’d read the reports from the professionals and knew the recommendations. I didn’t understand what was happening.

I heard my husband’s voice over the phone speaker as he asked the first question. As I tried to focus on his words I found myself desperately wishing we were in the same room for this meeting. I quickly followed-up with a few other questions of my own. What about her need for a high-level of supervision? How was therapeutic foster care environment going to be different from what we were already providing at home? Was there anything we could do to help them reconsider the decision? The answers made it clear the decision was final. We could accept that service or our case would be closed.

I’m not sure at what point I started crying. As the meeting concluded I was left sitting with our clinician, tears streaming down my face. I pulled myself together, gathered up my kids from the waiting room, hugged my mother-in-law goodbye, and called my husband from the parking lot.

“This isn’t about our parenting or her needs. It’s about the system and how they function. We have to play their game. And if we do maybe eventually we’ll get to the place where we can access the services she actually needs.” He was right, accepting this service was really our only option. But it felt so unfair. Not just to us, but to our daughter. I headed home, tears stinging my eyes most of the drive.

Six months later, after a failed therapeutic foster placement, we sat in an intake meeting for the residential treatment program that her treatment providers had initially recommended. We never stopped advocating the entire six months, and finally, after the safety of other children had been put at risk, the system listened.

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While most children and youth with serious emotional and behavioral challenges aren’t likely to “outgrown” all of those challenges, there will likely be years when they need fewer services. And there will also be times when they need additional services. Here are a few challenges parents may experience when advocating for the right level of services:

Parent and youth voice don’t seem to influence treatment planning. Sometimes it feels like decisions have already been made before a conversation occurs. Or maybe parents and youth are invited to share their perspective, but the voice of the system carries more weight in the final decision. Although an appeal or complaint process may exist, those procedures often feel challenging for parents to navigate.

System priorities are used as an excuse for not providing services. For example, principles of care such as “community-based services” and “least restrictive environment” are difficult to meet when there are barriers to accessing services. If a service isn’t available in a child’s community the family may request to access a higher level of care or travel outside of their community for treatment.

Many children’s mental health systems have become “fail first” systems. In order for children and youth to access a higher level of support in these systems, they must first “fail” at each prior level, even if medical necessity has determined a higher level is needed. This can delay much needed treatment and create additional trauma for the child and family.

In order to support parents and youth, a system of care should have a fully developed and accessible spectrum of services. Additionally procedures should be established to allow for ease of movement along that spectrum as a child matures and family needs change.

If you’re a parent in a system that is transitioning or isn’t yet child-centered there are some questions you can ask to help the system work in a more supportive manner.

  •  Is this the right service for my child based on their needs and strengths or is it simply the only service that’s available? Asking this question helps the system identify gaps in services as it creates a more complete spectrum of services.
  • Are there other ways we can access a needed level of service that may not be currently available? Utilizing technology resources or paying transportation costs for therapists or families may increase accessibility to a service. While it is important to maintain fidelity with evidence-based treatments, there are still creative ways to meet needs.
  • *These are the needs and strengths of my child. How can we address these in the treatment plan? Even in a system that doesn’t utilize the CANS (Child and Adolescent Needs and Strengths) or a similar communication tool, parents can develop a list of their child’s strengths and needs to help guide the treatment planning conversation.

 

Advocating for the appropriate level of care is one of the most challenging tasks for parents navigating children’s mental health systems. When systems develop the full spectrum of mental health services and create procedures focused on meeting the needs of the youth, advocating for services becomes less of a battle and more of a journey.


Be sure to return to the homepage for an overview of the full series and how to contact Jennifer Griffis directly!

Moment of Crisis, Part 3/4

Parenting with hope through the hard places by Jennifer Griffis.
Visit the homepage for the full series!

“I don’t think she can safely return home right now. Do you have any other options? Are there any family members who can take her?”

My husband and I sat across from our daughter’s case manager as she continued, “I just don’t think she can safely come home. The risk is too high.”

This was supposed to be a treatment plan meeting. Our daughter had been home from residential care for almost six months. Already we could feel her behaviors beginning to escalate. We needed more support, so we scheduled a meeting with the case manager. But before the meeting happened our family experienced a crisis. We could no longer safely manage our daughter’s behaviors at home and she was admitted to the psychiatric hospital.

Her treatment team was supportive of a residential care placement. She met the criteria for medical necessity. While our hearts wanted her to be home with us and her siblings, we knew this was the best treatment option for her at this time.

As the meeting continued we learned that even with treatment team support our state’s funding approval process would take 6-8 weeks. And if it was initially denied (which often happened) the process would take even longer. The behaviors that initiated the crisis had been extreme, and the amount of trauma inflicted on all of the children was significant. Members of the treatment team agreed that it wasn’t safe to have all of them together until we’d had the opportunity for intensive therapy.

Our daughter was going to be discharged from the hospital in a few days. The system had no options to help us reduce the risk of another crisis and no options for a short-term placement. In the knowledge of that reality we made the difficult decision to send the rest of our children to stay with family while we worked to manage behaviors, fill out applications, and attempt to avoid another crisis-related hospitalization.

It was a long seven weeks for all of us.

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Families walking through a mental health crisis often face similar challenges. Here are a few of the most common:

A visit to the local emergency room is often the recommended crisis option. While many families have access to a crisis hotline through their behavioral health agency or treatment provider, few communities actually have a full array of crisis services. When parents don’t have access to services such as crisis stabilization or crisis respite, they often end up in the local emergency room. When it has been well-equipped as part of a larger mental health crisis support system, an emergency room can be effective option. Unfortunately many families head to the emergency room during a mental health crisis because they have been told it is their only option, not because it is the best option.

Experiencing a mental health crisis sometimes feels like a requirement to get into higher levels of service. Parents and providers can often tell when a child or youth is showing signs that they need a higher level of support. Typically these signs are subtle at first and may be difficult to document to others outside of the child’s direct treatment team. Many parents feel like it takes a crisis before the system responds to their request for additional services. The use of a tool such as the CANS can help increase communication about even a subtle shift in the needs of a child or youth and help avoid a crisis.

The system response to a crisis is slow or nonexistent. A crisis signals that a shift in services is needed. Maybe the frequency of a service needs to be increased or a different array of services is required to meet the current needs of a child. In order to effectively respond to a crisis this shift needs to be immediate, but systems are rarely designed to move quickly, especially when it comes to approving funding for additional services. The reality for many families is that the risk of another crisis increases when approval procedures within a system are too slow.

In order for systems to deal with crisis well they need tools to identify families at risk of experiencing a mental health crisis, accessible crisis support services, and timely access to appropriate treatment services after a crisis. For those parents navigating systems that are still creating effective mental health crisis services, there are ways to help support your child in a crisis, even if the system falls short.

  • Know what will determine a “crisis” for your family. The exact situation that defines a crisis is unique for each family. It may be influenced by job responsibilities of parents, ages and emotional needs of the siblings, availability of system resources, the behaviors of the child, and many other factors. It’s also important to remember that your definition of crisis will change over the years as family situations shift and as children grow and mature.
  • Follow the current crisis procedures, even if they include options you might like to avoid, such as a trip to the emergency room or calling law enforcement for support. It’s also a good idea to educate yourself about your rights and your child’s rights within each system before a crisis occurs. Utilizing the current crisis system and being willing to share your experiences with others can help move a transitioning system toward more effective crisis services.
  • Have backup plans to deal with the aftermath of a crisis and the slow timelines that often exist for systems in transition. These plans might include support from extended family members, community services that fall outside the mental health system, or creative solutions based on your family’s unique strengths.

An effective system of care views a crisis as an informing experience, a time to learn more about a child or youth and respond in a way that reduces the risk of another crisis. A family supported during a crisis is also likely to develop trust in the system, which strengthens relationships between all system partners, creating a stronger more effective system for children, youth, and their families.

crisis1crisis3


 

Be sure to return to the homepage for an overview of the full series and how to contact Jennifer Griffis directly!

Discharge Planning, Part 2/4

Parenting with hope through the hard places by Jennifer Griffis.
Visit the homepage for the full series!

“Here’s the discharge summary. There’s a follow-up appointment for medication management in two weeks. She has an appointment for therapy next week. And here is all of the information on her medication. I just need you to sign here and then I’ll go get her for you.”

After the nurse left the room I turned to my husband, “That’s it? We just take her home now? What do we do if she does this again?”

It was our first discharge experience at a psychiatric hospital. Our daughter, who was six years old, had been there for the past ten days after attempting to kill a sibling and demonstrating some highly concerning thought patterns. We had made the decision to admit her with the hope of finally getting some answers about what was causing the behaviors and how to move forward as a family. But as I walked out of the hospital holding her hand, it felt like all we’d gotten was ten days of respite. I wasn’t sure when, but I knew at some point we’d be back. The question was how long could we survive before it happened again.

The next morning I went to have coffee with a friend. When I got home her behaviors were already beginning a downward spiral. My husband and I spent the afternoon trying desperately to “reset” her, but despite our efforts her behaviors continued to escalate. Eventually we made the decision to head back to our local emergency room for a mental health evaluation. Less than 24 hours after being discharged she was being admitted back into the hospital.

In the medical world it’s called “bounce-back”. In criminal justice it’s called “recidivism”. In the mental health world we hear both terms. It means a person leaves a system and within a defined period of time returns back to the system they just left.

Over the course of the past five years our daughter has experienced three bounce-back admissions to in-patient psychiatric hospitals and had a re-admission to residential treatment after only six months in a community setting. Situations like this are common among children with untreated mental health issues.

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“Bounce-back” admissions and recidivism rates are something that systems track and attempt to avoid. High rates in these areas are not a mark of a healthy system. So why is it common for families of children with a serious emotional disturbance to experience multiple hospitalizations in a short time or to find themselves back in a court room or an treatment center intake room only weeks or months after leaving? Here are a few reasons…

  • Lack of communication in systems. A larger urban hospital may recommend a service that isn’t easily accessible in a smaller community. Or maybe an outpatient clinician’s assessment of a child isn’t easily available to the inpatient therapist. When agencies and organizations fail to effectively communicate with each other, parents are left with the responsibility of piecing together services and providers to support their child’s treatment.
  • Lack of practical crisis planning. Giving a family a crisis number at the time of discharge is not a crisis plan. Neither is writing down a list of coping strategies. Crisis planning goes beyond these ideas and provides practical steps that a family can take when a crisis happens, including the names of professionals who will support them in those moments.
  • Lack of treatment services. Quite often the services a child needs just aren’t accessible. Maybe it’s due to funding challenges, living in a rural location, or not being part of the “right” system. Finding ways to remove the barriers to appropriate services is critical to reducing the chances of readmission.

My state is in the process of transitioning to a more child-centered children’s mental health system. Recently I participated in a discharge meeting that left me feeling amazed and hopeful. As professionals from multiple system partners were discussing the services my daughter would need after discharge from residential treatment, one of them said, “If we don’t have the right level of care available within the community then we should consider delaying discharge while we work to get those services in place. We have to make sure the level of care matches her needs.”

If you’re a parent navigating a system that isn’t yet child-centered in its discharge process there are ways you can help the system move in that direction.

  • Ask questions to help point out the gaps in crisis services. For example, “Is the ER the most appropriate place for me to take my child in crisis, or is it simply the only option?” or “What exactly is going to happen when I call this crisis number?”
  • Share details about the services that are available in your community. Often administrators and clinicians working in other parts of a state or region are not aware of the specific services available, or lacking, within a community. Instead of leaving them to make assumptions about services based on incomplete knowledge, help educate them.
  • Encourage practical discharge conversations soon after admission. While discussing discharge criteria at the moment of admission is good clinical practice, these conversations often leave parents feeling fearful and anxious. A discharge plan helpful to families should include discussions about services needed after discharge, as well as therapeutic and medication goals for the child.

Comprehensive, practical discharge planning is possible when parents have the opportunity to participate in authentic conversations about needed services and supports for their family. This can be a positive step in helping children and families receive the care and support they need within their own communities.

Entering the System, Part 1/4

Welcome to the first post of a 4 part series written by Jennifer Griffis. Visit the homepage for her series for a full look into their experiences.

“The treatment team is recommending long-term residential placement. Have you filled out an application for Children’s Mental Health services?”

I was sitting on the floor of my bedroom, door closed and phone pressed to my ear. At best I only had a few minutes of quiet before a child came looking for me, desperate for a snack or ready for a snuggle. It had been a hard few weeks for all of us. I tried to comprehend the words of the hospital social worker on the other end of the line.

“No. Do we need to?”

“It’s the only way to access residential treatment services in Idaho. I’ll email you the contact information for your region.”

As I hung up the phone, tears started flowing. This was our daughter’s second psychiatric hospitalization in just three weeks. She was only six years old. Medication wasn’t working; outpatient therapy and parenting classes were also proving unsuccessful. While a solid diagnosis seemed elusive, the behaviors were concerning for everyone involved.

The idea of my six year old spending months in a residential treatment center was overwhelming. But even those concerns paled in comparison to the necessity of entering yet another system in order to access that care. A system that, on the surface, looked like it might be connected to child protection services. I wasn’t thrilled about opening our lives up to strangers…especially in the midst of the uncertain chaos we were facing as a result of our daughter’s mental health challenges. Would they think this was our fault? Would we risk losing our children? Would they believe what we were saying?

But we knew that residential care was the only way we were going to make progress, both diagnostically and therapeutically. We’d exhausted all of the other resources, so with trepidation I began filling out the application.

************

Families enter into children’s mental health systems in a variety of ways. Sometimes it’s by filling out a voluntary application after being referred by a doctor, therapist, or school counselor. Other times it’s court-ordered, maybe through child welfare or juvenile justice. Regardless of how a family enters the system, there are some common challenges…

  • “I don’t understand why I have to fill out another application. How is this system/service/agency different?” Filling out applications to different agencies within the same system is time consuming and confusing for parents. It highlights the lack of communication and information sharing between system partners.
  • “I’ve been transferred to four different people and still can’t find anyone to answer my question.” Even within a larger state system, professionals working within specific agencies or departments rarely have knowledge about how the system works as a whole. This leaves parents who are entering the system struggling to find answers to their questions. They often ask the wrong person. And that person, although well-meaning and knowledgable about their own work, doesn’t have enough system knowledge to direct them to the right person.
  • “It feels like the decision has already been made, even before I make the request.” When systems are focused on their own policies and procedures instead of the needs of the children and families seeking their services, parents may feel as if the decisions were made without their voice being heard.

A system that is child-centered instead of system-centered will help support parents through the process of entering the system. It will help parents fill out the application, provide a warm handoff between system partners, and help answer questions about all aspects of the system in ways that are easily accessible.

While there are systems that do this well, many of us are currently accessing services for our children within systems that are either transitioning to a child-centered model or are still firmly system-centered. Even in these systems there are ways you as a parent can help the system work in a more family friendly way.

  • Ask questions. If you find yourself frustrated by the way something in a system is functioning, instead of complaining try being curious. Ask questions of the professionals working in the system. Just like people, systems often function out of habit. By asking questions about the specific area of your frustration, you may help highlight needed changes others haven’t noticed.
  • Request a meeting. If your child is engaged with multiple system partners request a meeting with representatives from each group. Just getting everyone at the same table to discuss your child’s and family’s strengths and needs can help shift the perspective and encourage collaboration.
  • Talk with another parent. Find a parent who has walked through the system recently. If you can call a local or state advocacy organization they may be able to connect you with a parent who can offer you advice for navigating a system that is in transition. And if you’re a parent who has been navigating a system for a while, reach out to your advocacy organizations and offer to be a point of contact for other parents entering the system.

Entering a children’s mental health system is a challenging moment for any family. By working together we can make the transition empowering for parents and encourage their further engagement in the treatment process.

 

 

 

 

 

 

 

 

 

 

Remembering Trauma Part 2

Earlier this summer, Drs. Cassandra Kisiel and Tracy Fehrenbach, at the Center for Child Trauma Assessment, Services and Interventions (CCTASI) at Northwestern University, a partner in the National Child Traumatic Stress Network (NCTSN), launched a public awareness campaign and short film entitled “Remembering Trauma: Connecting the Dots Between Complex Trauma and Misdiagnosis in Youth.” This 16-minute film highlights the story of a traumatized youth from early childhood to older adolescence, illustrating a wide range of complex trauma reactions as well as interactions with providers working in multiple service settings.

We are excited to announce the official launch of “Remembering Trauma, Part 2: Expert Commentary,” which is now available for viewing on our website, www.rememberingtrauma.org. Part 2 of the film includes poignant trauma-informed commentary from real world professionals while incorporating scenes from the narrative Part 1 film. Interviews include professionals who work across child-serving settings, including school, juvenile justice and mental health.  We hope this version of the film will be a useful resource in training and education, in your work with both family members and providers across a range of service settings.

DISCLAIMER: This film is inspired by a true story. This story shows the various ways that trauma can impact youth. It contains adult language and includes scenes with family violence and sexual assault, which may be upsetting to watch. It is strongly recommended that you view this film in the presence of a trusted adult that can offer support as needed.

“Remembering Trauma Part 2” incorporates scenes from the narrative Part 1 film, with poignant commentary from real world professionals who work across child-serving settings, including school, juvenile justice and mental health.

Visit www.RememberingTrauma.org for additional stats and resources.

For questions about this post and to find out how you can get involved, contact the CCTASI team at, cctasi.northwestern@gmail.com

Facilitated Collaborative Inquiry: Evidence Part 4/4

Facilitated Collaborative Inquiry: Evidence Part 4/4

by Stephen Shimshock, PhD
Director of Systems-Data and Reporting, Casey Family Programs

Evidence

This post is the final part of a four-part series on Facilitated Collaborative Inquiry (FCI). In the previous post (From Stories to Hypotheses) we explored how to engage staff in unpacking the stories behind the data, specifically data that showed a difference in permanency outcomes for a sub-group of youth. Additionally, we examined how to use the themes from the stories and the data about the stories to encourage staff to form hypotheses about the differences in outcomes. All this information was used to set a goal in the “X to Y by When” format. Staff can then engage in the process (typically over the course of 12-18 months) of testing their hypotheses by trying various strategies and monitoring progress in an effort to close the outcome gap for the identified sub-group of youth. In this final post we will talk about how an FCI cycle comes to a close. As staff test out and refine their strategies they are developing an evidence base, both of things that are working and things that may not be working as originally thought. These lessons learned are summarized in a structured report that can be shared with others.

Before talking about summarizing an FCI cycle, it is important to revisit the concept of organizational culture change. In the first post it was stated that while the goal of FCI is to improve outcomes for youth and families, an equally important goal is to develop a culture of “best practitioners.”

By engaging staff in every aspect of the inquiry process they naturally become more curious about understanding the underlying challenges affecting outcomes as well as more creative in their pursuit to find solutions to those challenges. As an FCI cycle comes to a close you should not only see changes in outcomes, but you should also see changes in the staff. You will hear it when they talk about their cases. You should see increases in their communication with each other and their partners.

One of the core aspects of TCOM is that we are in the business of transformation. Transformation shouldn’t be limited to the youth and families we serve, it should extend to all of us. The hope is that each person participating in the child welfare system becomes better at what they do. Social workers become better social workers, supervisors become better supervisors, evaluators become better evaluators, etc. The notion of a culture change is an important aspect to keep in mind when developing a summary report. The summary report will likely identify strategies that worked with the target group of youth; however, those strategies were used within a learning culture (or a culture of “best practitioners”) and they may not be as effective if used outside that context. We have to embrace that there isn’t one magic formula to eliminate the need for foster care. We need to employ a combination of “best practices” in the hands of “best practitioners.”

Throughout the FCI process there are several mechanisms to track progress over time. In the previous post we discussed the importance of staff developing a “cadence of accountability.” This is a short, regularly scheduled meeting where staff can talk through what strategies they are trying out, what is working and what is not working. In addition to the cadence of accountability we schedule regular check-ins with staff to document their progress (these can be monthly or quarterly meetings). The basic idea is to keep a running log of progress to help summarize the entire FCI cycle at the end. Since staff set a goal in the “X to Y by When” format, there is a clearly defined timeline for the FCI cycle. This doesn’t mean that all work comes to a stop; rather rigorous examination of the strategies and data can help staff learn how their hypotheses are playing out. This allows them to make decisions about whether they need more time to refine their strategies or if they have made enough progress to focus on a new area of practice.

We do have a more formal closing session, typically a full day focused on the overall measure of progress toward improving outcomes for the targeted group of youth. In the previous post we provided an example goal: “We want to increase permanency for youth who enter our program with five or more actionable items from 38 percent to 50 percent in the next 18 months.” Obviously, the closing session would occur somewhere around that 18th month and we would look to see if the percentage in permanencies increased, decreased or stayed the same. We use a similar story process, as described in the previous post, to examine the cases that had closed and look to find themes about strategies and interventions that worked.

The information from the closing session is incorporated into an FCI Summary Report. This report follows the four phases of FCI and describes how an office came to discover the group of youth having different outcomes than others; how they set a baseline and a goal for that group; how they developed a working theory and/or a set of hypotheses they could test over time; and, ultimately, summarized their lessons learned. It is important to have a structured format to the report, especially if you are working across multiple offices. This way readers could orient themselves to the structure of the report once, and then they could read about a variety of topics across many offices. Currently our summary reports are written in collaboration with our offices. Our hope is to transition to a place where the offices take on the majority of authorship and tell their FCI story with their own voice. In addition, we plan to make our FCI Summary Reports available to everyone. We are hoping to make our first one available by the end of 2017.

FCI is both a continuous quality improvement process and a systemic intervention. As mentioned, we want to find youth whom our system is struggling to serve well and improve the outcomes for those youth by relying on the creativity and expertise of our front-line staff, management teams, and collaborative partners (including youth and families). In addition to improved outcomes for our youth and families, we also hope to see staff (at all levels) getting better at what they do by creating and cultivating a culture of best practitioners.

FCI: From Stories to Hypotheses Part 3/4

Facilitated Collaborative Inquiry: From Stories to Hypothesis Part 3/4

by Stephen Shimshock, PhD
Director of Systems-Data and Reporting, Casey Family Programs

This post is part three of a four-part series on Facilitated Collaborative Inquiry (FCI). In the previous post (Using Data to Show Differences in Outcomes) we examined ways to identify subgroups of youth that may not be having the same outcomes as others. The example given in the previous post was somewhat simplistic (youth with five or more actionable items in the behavioral, life functioning and risk domains as identified using the CANS at baseline). In an implementation of FCI you would likely explore a variety of potential variables. However, we will continue with the previous example in this post to keep things consistent. In this phase of FCI we explore how to engage staff, through the use of stories, to unpack what they think could be causing the differences in outcomes for youth. Establishing a measurement baseline and a working understanding of what may be causing the differences in outcomes is the foundation from which staff can then set a goal for improvement.

In the previous post the entry cohort data showed that youth with five or more actionable items in the behavior, life functioning and risk domains at intake were less likely to achieve permanency than those youth with four or fewer actionable items. Only 38 percent of the youth with five or more actionable items achieved permanency after two years. This outcome establishes a baseline from which staff can then set improvement goals. Once the baseline is established, the staff then work together to understand why our system is struggling to serve this population of youth. Axiom two from the previous post states, “Those that exit teach us about the quality and efficiency of our system.” To look for patterns and causes we engage the social workers of cases that have closed in a “story session.” This is based on a belief that those closest to the challenges are in the best position to describe the challenges and find solutions.

The closed cases are methodically examined through stories and the collection of data about those stories. It is beyond the scope of this post to go into detail about the story collection process. However, we follow a similar process to Anecdote Circles[i] and many of the practices found in the book Working with Stories by Cynthia Kurtz.[ii] We typically do this work at an office level, so the youth we are exploring are only from that one office. This is a group process involving all staff in that office. A story collection session is conducted in about two hours, during which we collect 25-35 stories. As mentioned earlier, after each story is told the social worker (who told the story) completes a short (7-10) set of scaling questions about the story. In addition, those listening to the stories are writing on sticky notes when they hear a theme about a person, process or tool/form that resonates with them. As you can imagine, after two hours there are a lot of sticky notes collected in addition to the stories themselves. The staff then spend another one to two hours arranging all the sticky notes into clusters that make sense to them. They provide descriptive names for their clusters and then assign a cluster to each story told during the story collection session.

You may wonder how we can collect 25-35 stories in only two hours. The stories are told in response to “story eliciting questions.” These questions are typically crafted in advance with the guidance of the staff. The questions focus on specific events within a case rather than an open-ended case history. Here is an example of a story eliciting question from a recent FCI session: “Recall a time when a case took a surprising turn (either positive or negative); what, specifically, surprised you?” As you can see, these questions focus social workers on a specific experience and result in short (1- to 3-minute) stories or anecdotes. These can be very revealing and often highlight issues that may not be present in the data collected through the case management system.

In most FCI implementations, using data to find the differences in outcomes, engaging staff in unpacking the data with stories, and developing a working theory/hypothesis about the differences in outcomes is completed in one-and-a-half-day sessions. Most of the work is done on day one. In the evening of day one a small group synthesizes all of the information into what we call the “Opportunity Summary.” This report summarizes the opportunity/gap, establishes a baseline, provides charts that show patterns in the story data and also identifies the youth currently open that meet the criteria of the youth under study. The opportunity summary is used during a guided discussion with the staff to help facilitate the development of one or more hypotheses. The hypotheses can then be tested over time with new youth that meet the same criteria.

If, for example, we found an office had 40 youth currently open with five or more actionable items, we could say, “If we do nothing different than we are doing today, based on past performance, only 38 percent, approximately 15 out of the 40 youth currently in care, will find a permanent home.” This is often a palpable and powerful moment. We are not just looking at the “number” of youth but rather we are looking at the names of those youth. At this point, the staff are encouraged to set a goal in the “X to Y by When” format. In this example an office may state: “We want to increase permanency for youth who enter our program with five or more actionable items from 38 percent to 50 percent in the next 18 months.” At times this part of the process can be very challenging if staff are not used to working with goals or they fear not accomplishing the goal will reflect poorly on them.

It is worth emphasizing at this point that all through the FCI process we ensure staff that this is not a “got-you” process. This is a learning process. We have intentionally separated this process from other performance initiatives. In fact, in our organization, FCI is currently optional. Making it optional helps ease the anxiety of getting it “right or wrong.” In addition, as an administrator of FCI, it provides me with instant feedback of whether or not the process is helpful (people tend to stop doing things that are not helpful if they don’t “have” to do it). We want our offices to feel a sense of ownership of the process, and we want them to have some flexibility in how they implement it into their own unique office culture.

This takes us to the third and longest phase of FCI: implementing strategies and monitoring progress. The office now has an identified population of youth whose outcomes need improving, they have a baseline from which they can measure progress, and they will have one or more hypotheses about the causes of the difference in outcomes. Now, they can begin testing their hypotheses on specific cases. The office is encouraged to set up a “cadence of accountability,”[iii] a set of regularly scheduled meetings (typically around 15-30 minutes) where they can talk about what has worked, what has not, and what they are going to try next. Offices are allowed flexibility in how they accomplish this aspect of the work. To help support our offices, we hold monthly and quarterly check-ins where we can provide some structure to documenting their progress.

Overall progress is monitored through a “scorecard” that shows an office progress on their lag measure. While there are some suggested ways offices can track lead measures, we encourage offices to set up methods that best fit their own office culture. During this phase of FCI the facilitator serves as a consultant to the office, providing support and coaching as needed.

In the final post, we will talk about how we summarize the lessons learned from an FCI session and how staff identify their next opportunity. We will talk about the summary report and ideas for how we hope this can grow into a body of knowledge for child welfare professionals. Direct service staff are constantly busy tending to many youth and families and managing administrative work. If FCI is implemented as an “add-on” initiative it will likely fail. FCI needs to be integrated into their existing work. It is about rigorously examining cases to find those cases that would benefit the most from some focused attention. It provides visibility to the most venerable cases and encourages staff to critically think through solutions.

 

References

[i] Callahan, S., Rixon, A., & Schenk, M. (2006, October 19). The Ultimate Guide to Anecdote Circles. Retrieved July 15, 2017, from http://www.anecdote.com/pdfs/papers/Ultimate_Guide_to_ACs_v1.0.pdf

[ii] Kurtz, C. F. (2014). Working with Stories in Your Community Or Organization: Participatory Narrative Inquiry (3rd ed.). (n.p.): Author.

[iii] McChesney, C., Covey, S., & Huling, J. (2016). The 4 disciplines of execution: achieving your wildly important goals. New York: Free Press.

 

For more information on FCI please contact Stephen Shimshock, Director of System, Data and Reporting at Casey Family Programs 206-216-4178 (sshimshock@casey.org)

FCI: Using Data to Show Differences in Outcomes Part 2/4

Facilitated Collaborative Inquiry: Using Data to Show Differences in Outcomes Part 2/4

by Stephen Shimshock, PhD
Director of Systems-Data and Reporting, Casey Family Programs

This post is part 2 of a 4 part series on Facilitated Collaborative Inquiry (FCI). This post builds on the foundational material presented in the previous post . In this post we will explore the first phase of FCI: Identify the Opportunity/Gap.

In general, child welfare agencies aim to improve outcomes for the youth and families they serve. While it is easy to intuitively agree with that statement, it can be a difficult statement to operationalize and measure. Too often we (the child welfare community) leap right into designing solutions (actions we think will improve outcomes) without properly identifying and measuring the outcomes we plan to improve. The first step in FCI is to identify an opportunity for improvement by finding youth who are having different outcomes than others. This creates the time and space for us to get really clear on what we are trying to improve and how we will know if we made a difference.

There are three foundational axioms in FCI that help orient us to finding and understanding differences in outcomes:

  1. We believe that every youth and family that walks through our doors is a test of our system.
  2. We believe that the youth and families who have exited from our care can teach us about the quality and efficiency of our system.
  3. We believe that the youth currently active in our programs, and those yet to come, represent our opportunity to improve (Figure 1).

This foundation is important because it keeps the focus on our system in relation to youth and family outcomes. For example, if we find that a particular group of youth are not achieving outcomes at the same rate as others, we didn’t find “hard to serve youth” but rather, we found youth for whom our system is struggling to meet their unique needs and build upon their unique strengths. How do we adapt to serve that group more effectively? We examine those who have exited for clues (axiom 2). The ultimate goal is to motivate us into action by taking what we learn and applying it to those we are serving today and those yet to come (axiom 3).

Axioms

Casey Family Programs’ “system” (as per our Practice Model: https://www.casey.org/practice-model/) aims to ensure that youth are safe and feel safe, that they have legal and relational permanency, and that youth and families experience improved well-being. With this understanding of our system’s intent, we explore our data to learn which youth are achieving legal and relational permanency and which ones are not. We then examine our Child and Adolescent Needs and Strengths (CANS) data to see which youth are experiencing well-being improvements and which youth are not.

There are several methods you can use to find these differences. We have found that using time-to-event curves with entry cohorts are very effective in showing differences. One option is to use a formal Kaplan-Meier[i] curve, which you can generate using a statistical package such as R to visually show the time it takes to a specific event (e.g., attaining legal permanency) for youth in an entry cohort. We display our data in monthly increments. You can think of it as asking what happened to the youth after 0 days in care, after 30 days in care, after 60 days in care, etc.

Figure 2 shows two time-to-event curves (data are censured at 2 years) for our 2014 entry cohort. The cohort is segmented into two different groups of youth. The group on the left had five or more actionable items (2s or 3s) on their baseline CANS in the Behavioral, Life Functioning, and Risk domains. The group on the right had fewer than five actionable items in those same domains. The x-axis represents days in care (with Casey), and the y-axis represents the percentage of the cohort. The blue line signifies youth in care (it descends as youth exit). The green ascending line signifies those youth that exited to legal permanency and the orange line signifies those youth that exited without legal permanency. It is important to note that as a private foster care agency, Casey may have youth that exit the program but remain in foster care (unlike a state system in which youth are in care until they achieve permanency or age out).

fig2.png

From this graph (generated in Tableau) you can see that youth with five or more actionable items at entry were less likely (38%) to achieve permanency after 2 years than those youth that entered with fewer than five actionable items (62%).

This is just one example of a way to visualize differences in outcomes. As you explore your data you can find other patterns. You can even test hypotheses (this can be especially powerful if the hypotheses are coming from front line social workers). For example, you may want to know if a certain age threshold has an impact on outcomes. Visualizing the differences in outcomes and isolating specific issues will help identify youth that would benefit the most from more focused attention. Remember, we are finding youth for whom our system is struggling to meet their unique needs and build on their unique strengths. Interventions will not just be focused on youth and families, but will likely need to focus on systemic changes as well.

Once we have identified a subgroup of youth having different outcomes than others, the next step is to engage front-line staff in unpacking what the patterns mean. We need the “story” behind the data. In the next post, I will talk about how we engage staff in collecting stories about past successes and challenges with identified subgroups of youth. These stories serve as the foundation of their hypothesis or theory of what they think is causing the pattern. This analysis is a critical component of FCI, and it positions front-line staff as the primary analyzers of the data. This step emphasizes the “Collaborative” aspect of Facilitated Collaborative Inquiry.

 

References

[i]. Rich J. T., Neely J. G., Paniello R. C., Voelker C. C., Nussenbaum B., et al., 2010. A Practical Guide to Understanding Kaplan-Meier Curves. Retrieved July 11, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3932959/

 

For more information on FCI please contact Stephen Shimshock, Director of System, Data and Reporting at Casey Family Programs 206-216-4178 (sshimshock@casey.org)

Facilitated Collaborative Inquiry: Process Overview Part 1/4

Facilitated Collaborative Inquiry: Process Overview Part 1/4

by Stephen Shimshock, PhD
Director of Systems-Data and Reporting, Casey Family Programs

Process Overview

Facilitated Collaborative Inquiry (FCI) is a continuous quality-improvement (CQI) process that engages staff in every aspect of the inquiry process. The aim of FCI is to improve child welfare outcomes by building a culture of “best practitioners.”

What is a best practitioner? It is a staff person who is compassionate when working with youth and families, curious when analyzing data and patterns, creative when finding solutions to complex challenges, and courageous when challenging social norms to improve outcomes. In the context of FCI, a practitioner is both a social worker and a social scientist. They are agents of social change, and FCI is deeply rooted in a belief that social change can only occur through social interaction.

Best Practioner

The key elements of FCI are the facilitator(s), the collaborators, and the inquiry process. The facilitator guides the group through the collaborative inquiry process and provides support. The group works together to perform the bulk of the analysis, interpretation, strategy design, and progress monitoring.FQI

  1. Identify the opportunity/gap: Data are used to identify opportunities for improvement. For example, data can show differences in permanency achievement rates across different groups of youth.
  2. Establish a baseline and set goal(s): A baseline is established using data from the past. For example, data may uncover that older youth achieve legal permanency at a lower rate than younger children. The baseline will serve as the “current” rate. The goal is then established in an X-to-Y-by-when format. For this example, “We plan to increase the legal permanency rate for older youth from 45% to 75% in the next 18 months.”
  3. Develop a theory and corresponding strategies and monitor progress: Much of the work in FCI is done in this phase, which typically lasts 6 to 18 months. Practitioners are encouraged to develop theories or hypotheses about the possible causes of the differences they uncovered in phases 1 and 2. They are also encouraged to test their theories or hypotheses by implementing strategies and interventions, regularly engaging with each other to monitor progress, and adjusting their strategies accordingly.
  4. Lessons learned and next steps: At the end of the inquiry period the participants are led through a summary session to examine their findings and evaluate their progress in comparison to the goal they set for themselves. Based on their findings and learnings, they then determine whether they need to spend more time on the opportunity they have been tackling, or whether they want to move on to identify a new opportunity to address.

FCI has been developed from many influences, including Grounded Theory,[1] Action Research,[2] CQI literature,[3] and the Four Disciplines of Execution.[4]

FCI is a strategy implemented with groups to discover pressing challenges, develop a rigorous approach for making measured improvements, share lessons learned, and ultimately build a culture of evidence-based change. It is a collaborative and practical approach to social science rooted in the belief that communities, organizations, practitioners, youth and families are all participating in a complex dynamic social interaction, each changing in ways both big and small with each interaction. As such, simple solutions are difficult to achieve. FCI aims to create a culture where good data and best practices make it into the hands of best practitioners.

References

[1].      Glaser, B. G., & Strauss, A. L. (2012). The discovery of grounded theory: strategies for qualitative research. New Brunswick: AldineTransaction.

[2].      Greenwood, D. J., & Levin, M. (2013). Introduction to action research social research for social change. Johanneshov: MTM.

[3].      Wulczyn, F., Alpert, L., Orlebeke, B., & Haight, J. (n.d.). Principles, Language, and Shared Meaning: Toward a Common Understanding of CQI in Child Welfare. Retrieved May 11, 2017, from www.chapinhall.org/research/report/principles-language-and-share-meaning-toward-common-understanding-cqi-child-welfare

[4].      McChesney, C., Covey, S., & Huling, J. (2016). The 4 disciplines of execution: achieving your wildly important goals. New York: Free Press.

For more information on FCI please contact Stephen Shimshock, Director of System, Data and Reporting at Casey Family Programs 206-216-4178 (sshimshock@casey.org)

The Developing Communimetric Community

by Dan Warner
Executive Director and Founder, Community Data Roundtable

Originally posted June 19, 2017 on the CDR Blog. Click here to view more of their posts and follow their work.

I first met John Lyons in 2011 when he was doing a training in Pennsylvania.  Instantly impressed by his vision for how to measure outcomes in social services, I started up a conversation with him after his lecture, on the business model he was using to roll-out CANS.  I was confused: he doesn’t have an app?  He gives away the form and manual for free?  There isn’t a licensing fee hidden somewhere?

“No,” John explained to me, “and it’s not that I’m giving it away, either.”  John went on to explain that he is sourcing all of his users.  Trainers have to submit vignettes he can use for training, new CANS versions will improve the item definitions, analytic techniques he could never dream of will be used and provide insight far beyond his original vision.  The “TCOM” approach is built more on the model of Linux, Open Office, and Craigslist, where a central body gets things started and tries to organize the efforts of thousands of participants.  These independent efforts advance the field through their own application of the original ideas, allowing a whole ecosystem to emerge that is more creative and robust than a centralized model can accomplish.

One place that we see the power of this approach, is in the ongoing work people are doing across the globe in finding a right way to measure the “bottom line” outcome of a communimetric tool.  To get the conversation started, the Praed Foundation has put out two versions of their recommended “Reports Suite” which shows some basic, powerful ways that communimetric data can be aggregated to show outcomes for groups and programs.  At Community Data Roundtable we use many of these reports in both our online CANS app, the DataPool, as well as in the web-based dashboards we build for communities in which we are active.  These reports are clear, accurate, and helpful — and they are helping us at CDR build collaborative insight and action in the communities where we work.

But already, these reports are being innovated upon, and we are pushing towards the next level.  During the recent Communimetric Data Quarterly Roundtable that CDR hosts, we heard two presentations of groups who are building off of these original reports, to create new and innovative ways to measure a CANS “bottom line.”

First, Jesse Troy Ph.D. of CDR shared how we have been developing a Needs Improved to Needs Worsening ratio to identify outcomes.  This complicated model involves two ratios on top of each other – the percentage of needs that improved, over those that got worse.  In building the model we decided we didn’t want to use all of the CANS items on our tool, because that creates noise of all of these variables that may not be central to what a service actually treats.  Thus, to identify the items we should use, we used an original technique from the Praed Reports Suite, called MultiLevel Collaborative Formulation, in which the most salient treatment needs are identified using a certain reduction model.  As such, our new outcomes metric is building off of the MLCF and trying to take it to new levels.

Likewise, Allison Krompf of Northwestern Counseling and Support Services in Vermont shared how she has developed a “CANS Severity Score” modeled off the Praed Reports “Support Intensity” approach, which adds all the 2s and 3s together (counting the 2s and 3s, in order to give weight appropriately).  NCSS is doing many innovative things with this metric, including using it to derive a CANS value metric, which shows the change in severity over the per member per month costs of their population, to show the value of the change that CANS can measure.

These are just two examples of the ways that the original Praed Report suite is being incorporated, and expanded upon, by independent professionals joining the collaborative.  We can only imagine what next we will find.

For those interested to hear the presentations on these metrics, please contact Community Data Roundtable at info@communitydataroundtable.org.


Thank you Dan Warner for sharing your reflections!

 

Effectiveness of Functional Family Therapy for Mandated Versus Non-Mandated Youth

Dr. Katarzyna Celinska recently shared her article with the TCOM team entitled “Effectiveness of Functional Family Therapy for Mandated Versus Non-Mandated Youth.”[1] This article was originally published in the Juvenile and Family Court Journal and provides an overview of her extensive study comparing outcomes of youth mandated to participate in therapy versus those whose participation was voluntary. Using the CANS, she studies changes across all core domains of youth in Functional Family Therapy (FFT).

See below for an excerpt of Dr. Celinska’s article

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INTRODUCTION

Functional Family Therapy (FFT) is a short-term intervention for delinquents, status offenders as well as youth at-risk for delinquency along with their parents or guardians. Research presented in this article is a part of a larger quasi-experimental study conducted by this author between 2005 and 2013 with youth and their parents residing in the Middlesex County, New Jersey. The families participated in FFT as implemented by the Children at Risk Resources and Interventions—Youth Intensive Intervention Program (CARRI-YIIP) at the University of Medicine and Dentistry in New Jersey (UMDNJ), which has since merged with Rutgers University.

Research suggests that the most effective delinquency prevention interventions address skill building, counseling and/or provide multiple coordinated services. Many scholars indicate that family therapy and family counseling are among the most effective and successful interventions with FFT as one of the leading examples (Lipsey, Howell, Kelley, Chapman, & Carver, 2010; Lipsey, 2009).

This study compares the therapeutic outcomes of youth and their parents who were mandated versus those who were not mandated to participate in FFT. The sample is diverse in terms of gender, race and ethnicity. The outcome variables are scales obtained from the Strengths and Needs Assessment (SNA), a clinical and research tool completed by the therapists before (SNA initial) and after (SNA discharge) intervention.

The results of this study will contribute to our knowledge on FFT and to the literature on interventions designed to reduce delinquency and other risk behaviors. The findings will shed light on how mandating services impacts the outcomes while control-ling for observable differences between mandated and non-mandated youth. No other study on FFT has addressed the effects of voluntary versus non-voluntary participation. In fact, no published studies compare outcomes for mandated versus non-mandated youth in any other family therapy or intervention either. The findings of this research will suggest policy implications for the Family Court and the juvenile justice practice.

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To View the full text, click here.

Katarzyna Celinska, Ph.D., is an Assistant Professor in the Department of Law, Police Science, and Criminal Justice Administration at John Jay College of Criminal Justice, New York City, New York. Her research interests include evaluation of violence prevention programs and women’s incarceration. Her research was published in the Prison Journal, Journal of Juvenile Justice and Journal of Family Therapy. She is currently writing a book on criminological theory, criminal justice policies and practice in corrections. She teaches various courses including Women and Crime, Major Works in Criminal Justice and Policy Analysis.

Contact Dr. Celinska by adding a comment below or at kcelinska@jjay.cuny.edu

 

[1] Celinska, K. (2015). Effectiveness of Functional Family Therapy for Mandated Versus Non-Mandated Youth. Juvenile and Family Court Journal, 66(4), 17-27. doi:10.1111/jfcj.12049

 

Evidence-Based Health Policy – Caught in the Crosshairs of Politics and Health Reform

Thank you Dr. Purva Rawal for your synopsis on your recent publication. The following discusses major themes in context of current debates surrounding healthcare reform and the Affordable Care Act.

————————————–

By: Purva Rawal, PhD

Adjunct Assistant Professor at Georgetown University
Principal at CapView Strategies
phrawal@gmail.com

American healthcare is at a crossroads. The Affordable Care Act’s (ACA) passage in 2010 ushered in numerous changes to our health care system. While we are still understanding its impacts, Congress is pushing forward with an effort to repeal key parts of the law. The Congressional Budget Office’s (CBO) assessment of the House passed repeal and replace legislation estimated at leaving 23 million more Americans uninsured, and Medicaid funding would be reduced by $834 billion over the next decade. Despite a growing body of evidence on the ACA’s successes and areas where improvements are possible, the debate over our health care system seems mired in politics instead of progress forward.

The ACA has not only expanded coverage to millions, but it has mandated new consumer protections and benefits – including mental health and substance abuse services, and catalyzed widespread changes in healthcare payment to move from volume to value. As a result, systemic approaches to assessing and providing individualized care to individuals, such as the Transformational Collaborative Outcomes Measurement (TCOM) approach, are spreading more widely in healthcare. However, repeal and replace that does not assess the evidence of the law’s successes and failures could roll back coverage gains for millions of vulnerable Americans, weaken access to benefits that are essential for promoting health and well-being, and slow down the movement to value and population health. This post takes a closer look at some of the evidence and developments related to the ACA – away from all the politics.

The ACA’s Coverage Expansion and Insurance Market Reforms Are Improving Access to Coverage, Care, and Impacting Health

The ACA’s coverage expansion has increased health insurance coverage to an estimated 24 million individuals – approximately 19 million of whom were previously uninsured. The U.S. uninsured rate is at a historic low of 10.9 percent – compared to 17.1 percent in late 2013 before the ACA coverage expansion went into effect. In particular, Medicaid has played a significant role by expanding coverage to 12 million individuals.

Many of these gains have been made among low-income adults – including foster children that are allowed to remain on Medicaid until 26 years of age and parents. If legislation similar to the House-passed American Health Care Act (ACA) were to become law many of these individuals would become ineligible for coverage, and state Medicaid programs would see significant funding reductions as a result of capped Federal funding.

In addition to the coverage expansion, the ACA also mandated a number of reforms for the individual and small group markets to make access to coverage more equitable and to limit premium variation. Some of the most significant reforms included:

  • Prohibition on preexisting coverage denials,
  • Guaranteed issue for anyone seeking to enroll in a plan,
  • Limiting premium variation,
  • Ban on lifetime limits,
  • Allowing young adults to remain on parental coverage until 26 years of age, and,
  • Coverage for the “Essential Health Benefits” (EHBs), which include mental health and substance abuse services in all individual and small group plans, among others.

These reforms have been essential for guaranteeing access to insurance– especially to those with pre-existing conditions. These reforms, coupled with tax credits to offset the cost of coverage for eligible individuals and families, have made it possible to extend coverage to 10 million individuals through the regulated Marketplaces in 2017.

While major coverage reductions, funding cuts, and weakening of insurance market reforms are being debated in Washington, early evidence is demonstrating that insurance coverage is related to improved health status. A recent study published in Health Affairs, found that individuals that gained coverage under the ACA reported significant increases in a regular source of care, lower out-of-pocket costs, improvements on key health outcomes for chronic conditions, and better self-reported health. Demonstrating the impacts of the coverage expansion on low-income, vulnerable populations is critical to advancing evidence-based solutions that help more Americans gain coverage and improve their overall health.

ACA Is Transforming Behavioral Health and Emphasizing Outcomes Measurement

One of the ACA’s key goals was to move the healthcare system from paying for volume to paying for the value of services delivered. The Obama Administration set ambitious goals to shift health care payments in this direction. In 2015, the Department of Health and Human Services (HHS) announced goals to make 30 percent of Medicare payments to providers through alternative payment models, such as Accountable Care organizations (ACOs) and bundled payments, by the end of 2016, and 50 percent by the end of 2018. In 2016, the Administration announced it had met its 2016 goals early. States are also active in payment and delivery reform innovations. State Medicaid programs are driving payment and delivery reform, with initiatives such as health homes  focused on behavioral health.

The ACA – and in particular the Medicaid expansion – are bringing behavioral health into the spotlight as payers and providers are increasingly held accountable for patient expenditures and outcomes. While behavioral health needs have long been drivers of costs in Medicaid and in other markets, there has been little incentive to integrate those services into physical health settings until now. The ACA has increased access to these services, and is compelling commercial payers and large health systems to integrate and improve access to behavioral health services. Re-aligned incentives and increased access are creating new opportunities to address behavioral health – but premature repeal of the law could reverse these gains and trends.

Evidence Should Still Drive Decision-Making and Dialogue

The ACA has been one of the most politically and socially divisive issues the U.S. has faced in recent memory. Unfortunately, myths and claims about the law have dominated the public and policy dialogue on a complex law. Early evidence shows significant coverage gains, increased access to services – especially behavioral health, improvements in health, and a greater emphasis on outcomes measurement. While the debate in Washington DC could lead to major steps backward despite these gains, a continued commitment to research, building an evidence-base, and communicating results and opportunities for improvement to policymakers are critical to advancing the transformation providers and experts know is necessary and achievable across populations and systems.

Purva Rawal, PhD is an Adjunct Assistant Professor at Georgetown University, a Principal at CapView Strategies, and author of The Affordable Care Act: Examining the Facts.

 

For questions about this post or for more information on Dr. Rawal's work, reach out directly at phrawal@gmail.com

Planting a Seed of Wisdom

Thank you to Tracey Merachli for sharing her vision of the CANS in this poem.

Planting a Seed of Wisdom, December 2015

by: Tracey Merachli, tmerachli@children-first.ca

Resource Consultant-Children First

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Well let me tell you about my vision for the CANS.
It starts with listening to families and understanding their unique life and plans.

The life and plans that they experience each and every day
The struggles, challenges and especially STRENGTHS they see for their child, come into play.

We learn together by rating whether there is a need.
By encompassing a reflection of the unique child and family, and planting a little seed.

The seed is the vision that we all want what is best for our children on this earth.
We all have basic instincts and have experiences that mold us since our own given birth.

What is the best way to communicated then? To explore what is going on right now?
What means most to the child and what does their environment allow?

We all see various forms of art from different perspectives, right? So let’s put our thoughts together for discussion and this will shed us light.

For the light brings us hope, of any part of the day we despair.
It brings us hope to want to look at what we want or need to repair.

We can use strength’s and support as a centre-piece, to help you grow and build on the goodness of your child. We can look at needs to prepare us, to assess all the way from severe to mild.

There are 8 domains that can help us walk through the path we stroll.
There are 4 optional modules if needed of any possible vulnerability or needed awareness, and it’s free of toll.

What I mean is simple. “The seed” begins to grow with water and light.
You and I can approach this work together to discover a shared vision to make your family tree grow bright!

Take a walk with me on this wonderful CANS Journey

Italy Hosts their First TCOM Conference

May 25th and 26th saw the first Italian conference dedicated to the CANS and TCOM. Entitled “Particepicapzione e valuatazione di esito in eta evolutiva: Approcci collaborative in situazioni complesse, sanitarie e psicosociali.” The meeting was held in Milan and sponsored by the Fondazione IRCCS Policlinico, the conference involved presentations by national leaders in outcomes management approaches and reports from many sites around Italy who are initiating the use of the CANS in a collaborative approach to better serve children and families. Antonella Costantino, M.D. led the conference. Dr. Costantino is the Director of the Child and Adolescent Neuropsychiaric Unit at the Fondazione IRCCS “Cà Granda” Ospedale Maggiore Policlinico. The Policlinico has a team that supports the use of CANS and TCOM in Italy through training and technical assistance. Stefano Benzoni, M.D. and Alessandro Chinello both played key roles in the success of this inaugural event.

The meeting was a collaboration between the Policlinico and the TCOM team at Chapin Hall. John S Lyons, Ph.D. Nathaniel Israel, Ph.D. and April Fernando, Ph.D. all provided talks. Lise Bisnaire, Ph.D. from BORN Ontario at the Children’s Hospital of Eastern Ontario in Ottawa, Canada was another international speaker at the event. These talks are available through the attached links.Click HERE to view their full program of events.

Thank you to our partners all across the collaborative for all of the work you do!

Contact Alessandro Chinello, coordinamento.cans@gmail.com, with any questions you may have on Italy’s TCOM implementation, their use of the CANS/CAT, Policlinico and how to be involved in future conferences!

 

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Resiliency

Resiliency, as defined by the TCOM tools, is an individual’s capacity to identify and use their internal strengths to manage their lives in times of need and support their own development. Resiliency acknowledges an individual’s ability to “bounce back” from psychosocial consequences resulting from traumatic experiences. These experiences can range from traumatic life events such as sexual or physical abuse, witness to violence, or natural disasters to the divorce of parents or a change in schools. Any one of these events (and many others) can cause children to have strong feelings and reactions that impact their ability to function.  A child’s intensity of reaction to trauma is not a sign of weakness or failing. Many times these experiences are beyond anyone’s capacity to adapt, which affects their ability to recover.

Our last post featured and introduced a new campaign from  Center for Child Trauma Assessment, Services, and Interventions, at Northwestern University’s Feinberg School of Medicine. Here are some facts from Remembering Trauma

  • 26% of children in the US will witness or experience a traumatic event before they turn four.
  • Young children exposed to 5+ significant adverse experiences from 0-3 yrs are 76% more likely to have a delay in language, emotion, and/or brain development.
  • Over 50% of youth in detention have experienced at least 6 trauma incidents prior to arrest.

As we look at the statistics around child trauma and the effects of traumatic experiences, we identify Resiliency as a strength an individual holds. In fact, it is the ability of a person to recognize AND use their strengths.

Resiliency is a CORE item captured in the CANS (Child and Adolescent Needs and Strengths). It is an item that needs to be seen in three parts.

  1. Does the individual have internal strengths?
  2. Is the individual able to recognize their own strengths?
  3. And, are they able to use their strengths to support healthy development?

Resiliency

Remembering Trauma

The Substance Abuse Mental Health Services Administration (SAMHSA) held the 2017 National Child Traumatic Stress Network (NCTSN) All Network conference on April 25-27 in Arlington, Virginia. This year’s theme was “Serving Children and Families Who Have Experience Trauma: Building  a Trauma-Informed Nation.” With a continued commitment to raising the standard of care and improving access to services for children and families, the conference brought together individuals, agencies, and organizations from all over the world come together to share their work and educate the public.

The Center for Child Trauma Assessment, Services, and Interventions, at Northwestern University’s Feinberg School of Medicine, showcased their most recent public awareness campaign on complex trauma, “Remembering Trauma.”  As part of their campaign they created a short film and resource site in collaboration with partners from NCTSN.

“Remembering Trauma: Connecting the Dots between Complex Trauma and Misdiagnosis in Youth” is a short film (16 minutes) that highlights the story of a traumatized youth from early childhood to older adolescence by illustrating his trauma reactions and interactions with various service providers (including probation officer, school counselor, and therapist). This product was created in order to support the critical importance of using a trauma lens in our work within child-serving systems and the potentially detrimental impact of not incorporating a trauma framework. We believe this resource can serve as a powerful educational and awareness raising tool.

Visit www.RememberingTrauma.org for additional stats and resources.

For questions about this post and to find out how you can get involved, contact the CCTASI team at, cctasi.northwestern@gmail.com

 

EPISODES: Structure, Function, Management

By: Nathaniel Israel, PhD

EPISODES: STRUCTURE, FUNCTION, MANAGEMENT

*Episode—a container or set of parameters which define when a series of actions are expected to take place and when interventions have ceased

A building block of understanding a person’s care is being able to assign an Episode of Care to a person. Nearly all reports are based on expectations for, and the execution of, specific treatment-related activities with the hope that they lead to particular transformational outcomes. However, not all data systems create or manage episodes in a clear and consistent manner. Following our last post Unpacking the Standard Reports: Design for Decision Support, this post aims to highlight the core issues that need to be addressed in creating or managing EPISODES in a data system.

I. Episodes of Care: an Example

Let’s begin with an example of episode-based expectations for treatment events. In this example jurisdiction, there is an expectation that after a referral, a screening is completed within 10 days. After the screening is completed, a referral for a particular type of care is made. Then the expectation is that a full assessment will be completed, and appropriate care will be provided. When care is provided, treatments are expected to address specific targets which are objective, measurable, and amenable to change. Re-assessments and updated treatment plans provide evidence as to whether the specific targets are being addressed as intended. Discharge is expected to occur when treatment targets are achieved, or a different type of care is more appropriate (see Figure 1).

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All of these expectations are linked to each other. Each action and subsequent state creates the expectation of the following action, from referral to discharge. Any interruption in this causal chain has to be dealt with in a systematic way in order to understand and manage care in a system.

Episodes provide a ‘unit’ to all of these coordinated, interdependent actions. Episode-based rules are required to insure that all episodes have a consistent meaning, and that exceptions are handled in ways which are justifiable to regulatory and funding bodies as well as end users.  Episodes become especially important in complex healthcare systems, and for clients receiving care which is coordinated across multiple persons or providers. The more complex the care or organizational context in which care is delivered, the more important it is to be able to understand precisely what has been delivered, by whom, per which expectations, and leading to what outcomes. Without the ability to disentangle these actions and their providers we lose the ability to manage and meet expectations for transformation.

Because persons receiving care, persons providing care, and system requirements are all subject to change, both a defined episode structure and tools for managing episodes are required. Tools for managing episodes include both the routine assignation of opening and closure to an episode, assignation of reasons for opening and closure of an episode, as well as functionality designed to address clerical errors or record-keeping anomalies. The most frequently used tool in this list is an episode opening or closing function.

II. Defining an Episode

An Episode must specify the following design criteria:

  • criteria for an episode opening,
  • criteria for an episode closing,
  • and, criteria for associations with an episode.

Episode opening is typically automatically triggered in a system once a specific authorizing action has occurred. Increasingly in systems across the country, a referral for service eligibility is that triggering event. Episode closing also must meet specific criteria. These are often event-related, though they may also be time-related. For instance, discharge or drop-out from services are events which signal the closing of an episode. Episodes may also be time or location limited. Exceeding a time limit, or changing location may trigger the end of an episode. Both opening and closing criteria for an episode need to reflect local practice; they need to map to care as it is provided (or as it is required / intended to be provided, so long as these conditions can be managed when exceptions occur).

Associations with an episode may include the specific individual or team responsible for providing services / supports, the organization with which that person is associated, the geographic region within which care is provided, and the entities who provide administrative and policy functions associated with care. These associations must be defined as they have implications for table relationships in relational databases, and can be used to filter data and reports at each level of the system to provide people with the information they need to manage their decisions and practices (the ‘Management’ in TCOM).

Taking the time to define the conditions for episode opening, closing, and the associations linked to an episode of care allows one to structure your data in a meaningful way.  Specifically, it provides people with the information they need to make informed decisions about how well the system is working, at multiple levels, to facilitate the transformation of human lives.

III. Tools for Managing Exceptions in Episodes 

Failure to follow procedures for episode opening, closing, and reporting at the practitioner level may be intentional or unintentional, but leads to the need for administrative tools to be able to manage non-compliant episode structures. Administrative closure of an episode is one example of an instance in which administrative tools may be routinely used to manage non-compliance. Practitioners may also engage in behaviors knowingly or unknowingly which created invalid episodes. For instances, double-entering the same client’s screening or assessment results may open up two episodes of care simultaneously when only one episode of care is being provided. Tools for deletion of such duplication are necessary to keep the episode structure consistent and allow for meaningful comparison of practices and outcomes across episodes.  Additionally, there may be instances in which information about or within an episode needs to be preserved for record-keeping, but violates rules needed for use in reporting across episodes of care. For instance, a regulatory body may require that a partially-completed assessment is retained in the electronic record, when a practitioner who begins the assessment leaves the organization without completing it. Yet such an incomplete document may need to be suppressed when reports are run, as it is not appropriate for use in comparisons.

In order to generate reports which consistently reflect the treatment provided, its duration, and its effects, a suite of tools are required to manage episodes. These tools are most efficient when they are designed based on the types of exceptions which most frequently occur within a given system. These tools are often a mix of functions which practitioners, administrators and data analysts can apply to data in order to insure that episodes have a consistent structure and meaning when used in analyses.

In summary, use of an episode is necessary to make sense of whether expected service activities are occurring with a client, and what effect those activities are having. A consistent episode structure is necessary to insure that comparisons made are equivalent (‘apples-to-apples’) comparisons. Because changing personnel and system demands result in some episodes not being able to be closed in the expected manner, specific tools to address these episodes can be used to insure that comparisons across episodes remain meaningful for informing policy and practice. Contingencies likely to arise with children and youth served in human service systems, and the desired functions (tools) for addressing those contingencies, are outlined in the table below (Table 1). This table can be used to start a conversation with practitioners, supervisors, quality improvement leads and report developers regarding how to manage these situations and to insure that the effects of intervention are appropriately tracked and attributed to persons providing care.

Once a clear set of procedures are developed and implemented for managing episodes in a data system, you will find that the reports you develop are better able to identify where and to what extent persons served are experiencing transformation.  The data you provide within an ‘episode’ structure are better defined, easier to communicate, easier to understand, and give people credit for the transformation they help create!

 For more information on this post and the Standard Suite of Reports, contact Dr. Nathaniel Israel at nisrael@chapinhall.org

*Click HERE to view the pdf of the original report

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Standard Reports: Design for Decision Support

*September 2017 Post Update: Additional information added to the TCOM Report Suite. Click here to view the amended version.

The work we do across all levels and systems of care is a knowledge-based community connected to a variety of service settings including clinics, hospitals, state and local agencies. Ultimately, the goal is to improve the quality of care offered to the children and family we serve. Our success depends heavily on the ability to take all of the data, interpret it, evaluate it, and share it in ways that are most useful and effective to make meaningful decisions and change

A large number of individuals have collaborated in the development of all TCOM tools. Among these tools are the CANS, ANSA, and FAST. These information integration tools are designed to support individual case planning and the planning and evaluation of service systems. TCOM Tools are open domain for use in multiple child-serving systems that address the needs and strengths of students, adolescents, and their families. The copyright is held by The Praed Foundation to ensure that it remains free to use.  As users work through the data, agencies and organizations contract with various EHRs (electronic health records), to produce useful reports. With that in mind, the Praed Foundation has created a CANS Standard Suite of Reports required for all EHRs to build into their systems.

The Standard Report specifications which follow are designed to allow stakeholders to clearly specify how reports are to be designed and built. The specifications clarify the minimum standards for a report build of each of the Standard Reports in any web-based electronic reporting system. These are designed as a resource to the TCOM community. These specifications can simplify and standardize the communication between any individual or entity building these reports, and the persons who ultimately use them. Any electronic data system vendor who uses the CANS in an electronic reporting system, without payment to the Praed Foundation, is obligated to build reports to these standards. In this way we can share a standard language for talking about the strengths and needs of children, families, and our systems, and how we can empower each other to help children, families, and adults to live healthy, well, and connected lives in the community.

Click here to view and download the full Suite of Reports. If you have any questions about this document or developing reports, contact Dr. Nathaniel Israel, nisrael@chapinhall.org.

 

Managing the Business of Helping: Overcoming the Myths of Outcomes Management

*5/3/2017 UPDATE: 

Hope you enjoyed the Webinar! Click HERE to view slides used in today’s presentation.

by Tristan Keelan, TenEleven Group

TenEleven Group is pleased to sponsor a FREE webinar featuring Dr. John S. Lyons titled Managing the Business of Helping: Overcoming the Myths of Outcomes Management.

 Dr. Lyons has 35 years of experience in the pursuit, approach and implementation of outcomes management. Over the course of these experiences he has learned that many of the ideas about the nature of behavioral health intervention outcomes, though widely seen as truths, are incorrect. These false beliefs are referred to as the “myths of outcomes management.”

In this webinar, Dr. Lyons will provide a brief overview of some of the more common misconceptions surrounding outcomes. He will then present an approach that attempts to build on this learning and transcend some of these myths with the goal to create a more meaningful approach in how to effectively help others. This approach is called Transformational Collaborative Outcomes Management (TCOM) and has influenced the creation of the CANS and ANSA assessment tools among others.

 Learning Objectives:

  • Identify at least six common myths of outcomes management
  • Determine why collaboration is the recommended strategy for integrating and managing complex systems
  • Distinguish between the implications of managing a service and managing a transformational offering
EVENT DETAILS
Managing the Business of Helping: Overcoming the Myths of Outcomes Management
Wednesday, May 3rd
1pm ET / 12pm CT
Click Here to Register for the Webinar

If you are unable to attend your registration will allow you view a recording of the presentation.

Last year Dr. Lyon’s also spoke about outcomes myths at the TenEleven CONNECT conference.  You can read a reflection piece here: Dr. John Lyons and Spike Lee say: “Do the right thing”

About TenEleven Group

TenEleven is a software and services company providing solutions for health and human services agencies. Thousands of users in hundreds of offices use electronic Clinical Record (eCR™) to manage a variety of behavioral health service types. Learn more about TenEleven including the Treatment Wizard® for Trauma Informed Care at www.10e11.com.

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Rethinking Engagement in a High Staff Turnover Environment

By: Dr. John S Lyons

Engagement is the second key decision point in the TCOM conceptual framework.  Historically in most helping professions we have thought of engagement as primarily personal and often between two people.   A therapist engages a client in mental health treatment.    A substance treatment provider engages a person in their recovery process.   A case worker engages a child in child welfare.   While these personal relationships are clearly powerful and important in creating transformational experiences, we also work in environments in which the professionals change frequently.   It is not uncommon for therapists in public clinics to work one year until they get licensed and then move to more lucrative employment elsewhere.    Turnover rates in child welfare case worker positions have been reported between 20% and 40% annually.    The duration of a person’s experience in the helping system is often far longer than the duration of employment of any of the people who are charged with ‘engaging’ that person.   Our business model of trying to pay direct care staff as little as possible so that more people can be served works at cross purposes with our conceptualization of engagement.

Absent a major new investment in workforce salaries, this problem is likely to be with us for the foreseeable future.   So what can we do to facilitate engagement, recognizing that personal relationships with professionals are often transient in the public system?    One strategy is to broaden our concept of engagement to include institutional engagement.   In other words, we consider the “relationship” of people to be helped to be between those people and the programs and agencies they are involved in rather than simply between the person and the professionals who work in those agencies.    Forming a bond between a person and the program and/or agency that is attempting to help offers an additional route to effective engagement that may be less affected by high turnover.   If a person feels a meaningful connection to a program or to an agency then maybe they will keep working with different people in that program or agency.

Of all the agencies I have visited, perhaps the one that does this type of engagement the best is Boystown.    Given its well-known history, Boystown, as an institution, has a meaning that transcends the current staff.  In talking with youth served in various programs there, it is clear that while they talk about relationships with key staff, they also have a bond with the agency that goes beyond any personal relationships with individual professionals.   There are numerous agencies that have similar historical footprints that allow this form of engagement both in the U.S. and around the world.  I was affiliated with the Children’s Hospital of Eastern Ontario (CHEO) for six years.   CHEO has a long history in the community in the Ottawa region of Ontario which has resulted in a stellar reputation as a caring institution.  This reputation provides a buffer during times when individual relationships between professionals and patients and their families are problematic.

Of course, one way to help build ‘brand loyalty’ to a program or agency is through staff who are already committed to that program or agency.   Staff who are engaged in their work and share the values and mission of their employer are much more likely to be successful engaging the client/ customer/patient in the process of personal change.   Happy employees are obviously better at ‘branding’ a program and agency than bitter or disgruntled employees.

Another strategy for establishing institutional engagement is a history of effective service to others.   However, not all agencies have the advantage of long and distinguished histories of caring.   So what strategies can agency and program leadership use to increase engagement beyond ensuring engaged employees?  It is useful to look at the research on establishing brand loyalty as a framework for thinking through this type of engagement.  Ryan Westwood writing in Forbes magazine provides the following three keys:

  1. Your brand should inspire
  2. Your brand should be consistent
  3. Your brand should support your company’s core values

Making it clear that the agency or program is designed for the success of those who seek help and telling the story of that success is important.  It is inspirational.   Ensuring that every professional in the program or agency approaches the work in a similar fashion that is consistent with the values of the program or agency is also important.  These three recommendations describe the Boystown approach quite well.

Also in Forbes, YEC Women recommends the following seven tips (from “7 Tips for Building Brand Loyalty in a Discount Obsessed Market,” October 25, 2011):

  1. Keep quality high.
  2. Engage your customers.
  3. Solicit feedback from consumers.
  4. Give them a reason to come back.
  5. Stay relevant.
  6. Provide Value.
  7. Show your appreciation.

You can see how the strategies in TCOM are designed in a fashion that allows a program or agency to incorporate all seven of these recommendations into an essential structure of the core approach to its work.  Consensus-based assessment processes to engage immediately and stay relevant, followed by the use of personal status information to monitor and celebrate success and to demonstrate value and show appreciation for personal progress, are core processes of TCOM.

Even state agencies would benefit from this form of institutional engagement.  For example, when a state employee decides that the state will make a better parent than the current parents, even if temporarily, the state has the immediate responsibility of engaging that child as their own.   That is not simply the child’s relationship with their caseworker and foster parent.  It is also that child’s relationship with the child welfare agency.     Regardless of whether the “parent” is a biological parent, foster parent, or the state, or whether there is a therapist, case worker or other helping professional involved, engaging the person is critical to the success of the work, and we may need to find creative ways to do this in an environment of staff-level instability.


For questions on the post or to learn more, respond in the comments below or email jlyons@chapinhall.org

Collaborating To Address Child Trauma

by:  Gene Griffin, J.D., Ph.D.
Senior Fellow for Policy and Practice
ChildTrauma Academy

John Lyons, in his post of December 27, 2016, Complicated versus Complex: Implications for Collaboration, distinguished between a complicated system and a complex system. In a complicated system, all components and the result of their interactions are predictable. In a complex system, the final effect is not completely predictable. A helping system, such as a social service agency attempting to support a child who has been traumatized by abuse or neglect, can be viewed as a complex system. In this system multiple approaches are possible and there is no clear line of authority to determine how all participants must act. TCOM proposes that in such a complex social system the best outcome can be obtained by collaboration.  Thus, TCOM would argue for getting service providers, the family, and the child to reach a shared understanding of the child and his or her needs and strengths.

This understanding can be achieved via use of the CANS as well as other tools and perspectives. Recently John and Bruce Perry, M.D., Ph.D., have begun collaborating on an assessment process for children in New Mexico’s child welfare system who may be traumatized.  Dr. Perry is the Senior Fellow at the ChildTrauma Academy (CTA, http://childtrauma.org), a not-for-profit organization, working to improve the lives of at-risk children and families through direct service, research and education. CTA works to translate emerging findings from neuroscience, developmental psychology, and other related fields into practical applications for the ways we nurture, protect, educate, heal, and enrich children. The “translational neuroscience” work of the CTA has resulted in a range of innovative programs in therapeutic, child protection and educational systems. The core of the programs is its use of the Neurosequential Model of Therapeutics (NMT).

The Neurosequential Model is not a specific therapeutic technique or intervention; it is a developmentally sensitive and neurobiology-informed approach to clinical problem solving. While it has been implemented in multiple clinical populations across the full developmental spectrum (infants to adults), this approach has been most widely used with maltreated children. It is a way to use a child’s history in understanding that child’s current functioning. The approach structures the assessment of a child, articulates the primary problems, identifies key strengths, and applies interventions in a way that help family, educators, therapists and related professionals best meet the developmental needs of that child.

Both the CANS and the NMT use historical and clinical information to produce a functional assessment of a child. One way they differ is that NMT organizes the assessment based on a model of brain development and the possible impact of trauma. Under normal conditions, the brain evolves from lower to higher regions in a standard sequence. As this neurodevelopment is heavily shaped by a child’s experiences during each developmental phase and no two people share exactly the same experiences, each brain develops in slightly different ways. Therefore, the final result is not completely predictable.

This neurosequential development gets even more complex when trauma is introduced to the system.  Adverse experiences, just like positive experiences, shape the brain. But powerful, adverse experiences can have a negative effect, resulting in disrupted neurodevelopment.  The disruption will vary depending on where the child is at in his or her neurosequential development when the adverse experience occurs. Also, damage can be prevented or minimized by a child’s resilience and by protective factors, such as family support.

NMT assesses a child’s current neurodevelopmental functioning and compares it to a set of age-based norms. It generates a brain map heuristic, which identifies potential issues as well as available strengths and resources.  It provides a way to understand the child’s current functioning and suggests ways to move forward. NMT generates a set of educational, therapeutic, and enrichment recommendations that can be sequenced to further the child’s recovery and neurodevelopment. These interventions engage the child, the family and the community. Applied to child welfare, NMT gets clinical professionals, the child, and the family to reach a shared understanding of the impact of abuse and neglect on the child and to collaborate in their response. As TCOM argues, this collaboration should result in the best outcome for the child.

The CTA community of practice is comprised of over 30 independent but interactive “Fellows” and more than 50 training and project partner organizations in dozens of states and multiple countries. The “translational neuroscience” work of the CTA has resulted in a range of innovative programs being implemented in clinical, child protection and educational systems. In this regard, the CTA has become an international leader in creating and disseminating trauma-informed and developmentally sensitive practices and programs.

Collaborative partners are essential to getting the child-helping systems to work together in meeting the neurodevelopmental needs of children. John and TCOM bring the CANS and all its international resources and expertise to this collaboration with Bruce and the CTA in assessing the needs of traumatized children.  This partnership has the potential to produce major gains for children and families in the child welfare system. The initial discussions center on the development of a CANS algorithm that would identify children in the New Mexico child welfare system who would be most likely to benefit from NMT.  If successful, this model might transfer to other child-serving systems. Pursuant to TCOM, this collaboration is the best way to address the complex needs of traumatized children.

For more information on this post and the work being done at the ChildTrauma Academy, contact Eugene Griffin at e-griffin@northwestern.edu

Interactive Reports: A Feasible Goal for Any Organization

By Jesh Harbaugh, Assistant Director of Business Intelligence
Development, Evaluation, and Strategic Initiatives (DESI)
SENECA FAMILY OF AGENCIES

This is the last post of a 3 part series

In the previous posts of this series, Data is Only Useful When it’s Used and Increasing the Value of Your Data With Interactive Reports,  I’ve discussed the importance of setting up your data systems in a way that facilitates engagement and demonstrated how interactive reports can guide users to a deeper exploration and understanding of a topic.  Today, I’m going to share some key areas to consider as you pursue building interactive reports in your own organization, and I’ll spotlight our experience at Seneca Family of Agencies as an example of how one agency successfully navigated this challenge.  I hope to convince you that with the right approach, you can successfully build interactive reports in your own organization.

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Seneca’s Journey: A Brief Overview

First, some context: Seneca is a large service provider impacting over 17,000 youth and families per year in over 100 programs and service models throughout the states of California and Washington.  We pick up our case study a few years ago, when Seneca had a small team of two staff members responsible for all agency-wide evaluation, performance improvement, and data analysis activities, and analyses of data were primarily one-off projects done in Microsoft Excel and/or a statistical package such as SPSS.  (I describe these analyses as “one-off” because, even though the same analyses were often replicated at regular intervals, each dataset had to be compiled and cleaned or manually updated each time—a time-consuming and tedious approach, but which often feels like the only realistic option when an analysis needs to get completed on a timeframe.)

As you can imagine (and likely relate to), there wasn’t much time to explore new systems—evaluation reports for stakeholders had to be compiled, internal program requests for data analyses were fulfilled, and high-priority performance improvement activities needed to be completed.  Our journey began when one of the members on the evaluation/PI team heard about the “PowerPivot” add-in to Excel and did a little reading up on what it could do.

Since this add-in exists right within Excel (and many of the team’s analyses were completed in Excel), the next time one of the regular projects came up, they took a few hours to set up this one project to run with the new PowerPivot add-in.  (Without getting too technical here, PowerPivot is powerful part of Excel that uses what you could call “glorified Excel formulas” to turn what were previously manual analyses into automated interactive Excel reports that can be refreshed at the click of a mouse.)

From there, things quickly gained momentum—with each manual Excel analysis that was automated using PowerPivot, more time was freed up to repeat this process with other projects, and to build new, more complex analyses.  When Power BI (a new web-based platform for creating and sharing interactive reports and dashboards) came out in 2015, the team discovered that it was fully compatible with Excel and could take all the work that had already been done and provide a web-based platform to easily share live, interactive reports with other agency staff.

Before long, many of the typical reporting needs and internal requests for data were built as interactive reports on Power BI, where select staff can access the data they needed whenever they wanted.  Seneca’s implementation of Power BI went agency-wide in 2016, and every staff member can now engage with a wide range of data on-demand, including over 15 CANS-related reports along with many others related to client discharge outcomes, service provision and documentation, important incidents, placement changes, and academic performance.

That Sounds Too Easy… How Does it Really Work?

I’ll be the first to admit that it sounds easier than it actually is; of course, there are challenges along the way, some bigger than others.  But we’re living in a brand-new era of technology—one in which it’s entirely feasible for someone with no technical/IT background to create and share engaging interactive content online.

If you’re serious about building effective interactive reports internally (as opposed to contracting with someone to do it for you), you’ll need to make sure you find a way to address these three “essential ingredients” (in no particular order):

  • Staff Time
  • Skills/Technical Capacity
  • The Right Tools

 You might be thinking, “this reads like a list of the exact things my organization is most pressed for!”  But each of these can be overcome, and you will likely find yourself saving staff time while producing better analyses if you approach this the right way.  Let’s explore each of the areas above:

The Right Tools

The emergence of a new wave of software programs called “self-service business intelligence (BI)” tools has fundamentally shifted the landscape and made it possible for anyone create high-quality interactive online content which would have only been feasible for large corporations to afford 10 years ago.  To be clear, a “BI” tool is simply a program used to turn raw data into meaningful information.

These new programs are not only cheap or free, but are also relatively easy to learn, will increase the quality of your data analysis, and will save you loads of staff time once you’re up and running.  In addition to the efficiency and analytic power these tools bring, they also offer a wide range of compelling visualizations packaged with an accessible web-based platform that makes it easy to share your analyses with others.

A key piece of Seneca’s eventual success was the ability to start small.  Since Power BI and Excel were both either free or already part of Seneca’s existing Microsoft Office 365 software package, it was possible to test them out over time without needing to make any upfront investment or a major financial decision about the path to pursue.

Skills/Technical Capacity

The threshold level of skill required to effectively make use of tools such as Power BI or Excel (PowerPivot) is much lower than you might think.  In fact, it’s very natural for anyone who is familiar with Excel formulas or uses pivot tables to learn the DAX formula language (which is what Power BI and PowerPivot use)—many of the formulas are identical.  There are some great entry-level books for new users, and it’s an ideal professional development opportunity for staff who might be interested in developing their data-related skills.

Once you get into building more complex reports that merge multiple data sources together, you will want to develop an understanding of Dimensional Data Modeling.  But keep in mind that all of these concepts are completely feasible for someone with no technical background to learn.  The accessibility and familiar interface of these tools makes it possible to identify people within your organization who have skills or interest in Excel and develop them into interactive report designers.

Staff Time

This is obviously a tough one, but you’ll have to find a way to create even just a little space for a staff member to develop some skills/technical capacity as described above—and this could be as small as sending them to a one- or two-day training or carving out an hour or two per week for them to work through a book or video course.  Once they have some basic skills, they’ll need some initial time to apply those skills to an existing project and start automating the manual data analyses they’ve become so used to doing.  It’s all downhill from there!

The conversion of manual data projects to automated analyses in a program such as Power BI or Excel frees up hours of time down the road, and it’s the gift that keeps giving—not only do you never have to perform the same labor-intensive analysis again, but the data can be sliced interactively and your analysis becomes much more flexible, accessible, and useful.

If you’re considering setting out to develop interactive reports within your organization, I hope that this high-level overview provides you with a real-world example of how it can be accomplished and gives you an idea of some key areas to keep in mind.  It’s never been easier or more affordable to create systems that facilitate effective data use and informed decision-making!

 Are you interested in learning more about these tools or related topics?  Let me know by completing this brief survey—and if there is interest, I’d enjoy providing more focused content or training in the area that’s most useful to you.  Also, feel free to reach out to me directly: jesh_harbaugh@senecacenter.org.

 

For more information on this post and the work being done at Seneca, email Jesh Harbaugh at jesh_harbaugh@senecacenter.org

Increasing the Value of Your Data with Interactive Reports

By Jesh Harbaugh, Assistant Director of Business Intelligence
Development, Evaluation, and Strategic Initiatives (DESI)
SENECA FAMILY OF AGENCIES

This is the second post of a 3 part series

We expect a lot from front-line staff and treatment teams who work with our clients and families every day.  In addition to planning and providing high-quality clinical interventions, direct-care staff are usually required to document this work in a timely manner within an electronic health record.  There’s not much time left at the end of the day for a typical direct-care provider to analyze data—unless they experience the benefits of engaging with their data as outweighing the effort and time it takes them to access and consume it.

As I discussed in the previous post in this series,  Data is Only Useful When it’s Used, it’s our responsibility to create systems that make it easy and intuitive for stakeholders to consume high-quality, relevant information.  It’s paramount that these systems are designed with the user in mind and cater to their preferences, habits, and/or workflow.

With interactive, web-based reports and dashboards, we find an ideal mix of characteristics which align with the established habits of most people living in our modern, connected society.  People are accustomed to accessing content on mobile devices and have little patience for slow-loading pages.  We are used to rich, colorful visuals that draw us in, and dynamic movement and motion which keeps us engaged.  The more we can replicate that experience with our presentation of data, the more likely people are to engage with it.

By nature, the value of the information the user consumes from an interactive report will generally be greater than a static report, because they can easily explore new analyses and perspectives that are of particular interest to their role and skill set.  Let’s take a look at a very simple example that provides an opportunity to explore the percent of clients actionable on a given CANS item by their primary diagnosis.  (This was created in Power BI, a free business intelligence (BI) software program.)

2.1

This snapshot doesn’t initially look any different than a static report.  Along the top, we have a simple visual which primarily serves as a slicer, but also provides information by displaying how many clients were assigned each diagnosis.  The bar graph shows the percent of clients who were actionable on each CANS item on their initial assessment.  So far, so good, but nothing revolutionary.

Here’s what happens when I click on the “Neurodevelopmental Disorders” diagnosis category:

2.2

The report instantly shows us how clients with this specific diagnosis differ from the full sample.  You can see that the bar graph still displays a “shadow” of the original value, which serves as a benchmark to compare the new values against.  In this sample data, you can see that clients with Neurodevelopmental Disorders are roughly twice as likely to be scored as actionable on the “Impulse/Hyperactivity” and “Regulatory: Body/Emotional Control” items, and less than half as likely to have an actionable item score on the “Depression” item (compared to the full sample).

I’ll let you draw your own conclusions about how this approach above compares to presenting the same data in table form:

2.3

One of the core benefits of interactive reports is that they enable and encourage exploration, not just passive consumption of information. They are learning tools, not just attempts at information transfer.  Oftentimes, people expect data to give them answers, but as report designers, we should resist the temptation to think this way, and instead think of how we can guide the user to ask the right questions.  The scope of information contained in reports is often specific and provides a single perspective—not the multi-faceted view that’s required to understand the nuances of a complex issue.  A report serves to supplement to a user’s existing subject matter expertise, and it should amplify that expertise by helping them apply it more effectively.

In the example report above, we are initially guiding the user to ask the question, “what areas of need are most prevalent for clients with a diagnosis of [x]?”  Armed with that information, we ultimately want the user to ask, “what am I doing (and what should I do) to address the specific needs of clients with a diagnosis of [x]?”  This report certainly can’t provide that information, but it points the user down a path of deeper inquiry and action.  We can design other reports that can give insight into the effectiveness of specific interventions the user might decide to employ—for example, a report that shows changes in the percent of clients actionable on a given item over time.

Depending on your role and area of expertise, I’m sure you can think of other ways you might make use of this information or additional ways you’d be interested in slicing the data (in addition to diagnosis).

Most of us will likely agree that interactive, web-based reports are an ideal tool to have at our disposal—but how do you go about building reports like this for your organization? 

The next blog post in this series will detail one organization’s approach to successfully implementing interactive reports and outline some key considerations you should be aware of as you set out to build your own reports and dashboards.

For more information on this post and the work being done at Seneca, email Jesh Harbaugh at jesh_harbaugh@senecacenter.org

Data is Only Useful When it’s Used

By Jesh Harbaugh, Assistant Director of Business Intelligence
Development, Evaluation, and Strategic Initiatives (DESI)
SENECA FAMILY OF AGENCIES

This is the first post of a 3 part series

In the helping professions, few words elicit such strong and varied reactions as “data.”  In our culture of evidence-informed treatment, having strong outcome data to support your organization’s claims is essential, and there is immense value in having high-quality information to guide your decision-making.  But let’s be honest—there’s another perspective on the data revolution which is more focused on the drawbacks of “big data” than the benefits.

In fact, it’s reasonable to assume that many of our colleagues may not be particularly inclined towards data or think it’s very useful at all.  Their experience with data may primarily be one of frustration or indifference, based on their experience tracking, reporting, and being evaluated on what appear to be arbitrary metrics by an outside body with little direct experience or understanding of the client or family they might be meeting with each week.

I submit that both positions are valid and accurate.  Data on its own has no inherent value; a collection of numbers, regardless of how enlightening the information contained within it might be, means nothing unless the right person consumes that data.  Only at that point does the data become a valuable resource that can be used to improve performance and the quality of care.

This reality highlights the importance of the tools you use to analyze, present, and share your data.  If you want people to gain insights from your data, it’s not only important that the analysis (and data itself) be meaningful, but that it be easily accessible and presented in an intuitive way that a non-data-oriented person can make sense of.  We have to be practical and realistic in considering how people access and experience data—even sending an Excel spreadsheet as an email attachment (expecting the recipient to open the file and look at the contents) will prove too high of a barrier for many.

As stewards of data and information, we have a responsibility to meet people where they are at and present high-quality analyses in ways that facilitate a meaningful exploration of information.  The first important step is to know your users and understand what prevents them from engaging with data effectively.  Then, you can consider the best approach to overcoming these obstacles and determine what platform(s) best suits your needs.

No single approach is perfect, but interactive, web-based reports address many of the obstacles that were, until recently, very difficult to overcome for non-profit and helping organizations.  They are easily accessible from any connected device, offer colorful, engaging visual representations of data, and are flexible and responsive to user input—providing an ideal vehicle for sharing and facilitating engagement with data.  Once you have your data in a place where it’s most likely to be used, you’re well on your way to making effective use of it!

In the next post of this series, I’ll explore the value of interactive reports and share key considerations to take into account when designing them.

For more information on this post and the work being done at Seneca, email Jesh Harbaugh at jesh_harbaugh@senecacenter.org

The HEADS-ED: A Rapid Mental Health Screening Tool for Children and Youth

by: Mario Cappelli, PhD and Paula Cloutier, MA

Affiliations:  1Children’s Hospital of Eastern Ontario (CHEO), 2CHEO Research Institute, 3University of Ottawa

What is the HEADS-ED?

The HEADS-ED is a brief mental health screening tool that helps physicians to obtain a psychosocial history to aid in making decisions regarding patient disposition (e.g., admission, discharge, or requesting specialized mental health consultation).   The tool was designed by a multidisciplinary clinical and research team to match the existing psychosocial “HEADS” interview 5 as closely as possible by adapting it for emergency department (ED) use and adding a scoring component to assist with decision-making. Seven items representing specific components of the patient history are included (Home, Education, Activities & peers, Drugs & Alcohol, Suicidality, Emotions & behaviours, and Discharge resources).  Each item is rated according to three action levels: No action needed, Needs action but not immediate, and Needs immediate action. The levels were developed from the communimetrics theory of measurement which emphasizes the use of non-arbitrary levels that translate immediately into action.6  The levels are used to inform and facilitate decisions regarding patient disposition.

Why it was initially developed?  

Recent research shows that pediatric mental health presentations to the Emergency Department (ED) are increasing in Canada and the US.1,2 In order for physicians to use a screening tool in the ED, it must be brief, clinically intuitive, easy to complete and score, and help guide their decision making. Currently, there is no standard of practice or tool for physicians or non-mental health specialists to help guide the assessment and disposition of mental health ED presentations. The lack of an available mental health screening tool has been identified as a significant barrier by ED physicians in providing appropriate care,3 which would indicate that current mental health screening tools are not meeting their needs.

Completing the HEADS-ED:  

The HEADS-ED can be used to guide the psychosocial assessment and can be completed within a few minutes by a health care practitioner (physician or nurse) or allied health professional (crisis worker, school counselor) following the assessment.  It is available in a paper and pencil version or online at www.heads-ed.com.  The online version provides details about the tool, training videos and a mental health resource library (Figures 1-3).  It also has the functionality to help guide clinician decision making by 1) immediately providing a meaningful score; 2) suggesting if a consultation with a mental health professional may be required; and 3) identifying appropriate local community resources based on the needs identified in the ED to facilitate continuity of care.  An example of the website tailored for the National Capitol Region of Canada can be found at www.ottawa.heads-ed.com.

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Who is eligible?

The HEADS-ED was initially developed for use with children and adolescents between the ages of 6 and 18 years presenting to the ED for mental health care. Its use has expanded to school boards and mental health centralized intake services.

What is the evidence so far?  

The reliability and validity of the HEADS-ED has been established in two separate samples of pediatric patients presenting to the ED with mental health concerns7,8.  There are many barriers at the individual and system level that influence the successful integration of new practices and evidence-based research in clinical settings. To help understand the barriers for implementing the HEADS-ED, we conducted focus groups with participants from 6 different EDs across 2 provinces (Ontario and Nova Scotia) using the Theoretical Domains Framework.9-10 The study findings indicate that tailored implementation strategies are needed when using the tool in ED settings by taking into account site specific requirements. This methodology can serve as an implementation model for other services wanting to implement the tool.

What can be expected in the future?

The HEADS-ED currently is part of an Emergency Department Mental Health Clinical Pathway designed for a seamless transition from ED services to follow-up community services and is currently being implemented and evaluated in Ontario, Canada.11  We have also partnered with an academic team of healthcare providers in order to tailor and evaluate the tool for use in primary care settings.  A version for children under the age of 6 years old is also in development.

◊ A video describing the HEADS-ED tool and the website is available at:   http://www.ottawa.heads-ed.com/en/headsed/About_HEADSED_p3750.html

◊ For more information visit HEADS-ED or email Paula at PCloutier@cheo.on.ca or Mario at cappelli@cheo.on.ca

◊ To download the HEADS-ED form in English and French, click HERE.

References: 
1.  American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians and Pediatric Emergency Medicine Committee, Dolan MA, Mace SE. Pediatric mental health emergencies in the emergency medical services system. Pediatrics. 2006; 118(4):1764–1767
2.  Newton AS, Ali S, Johnson DW, et al. A 4-year review of pediatric mental health emergencies in Alberta. Can J Emeg Med. 2009; 11(5): 447-454.
3.  Habis A, Tall L, Smith J, et al. Pediatric emergency medicine physicians’ current practices and beliefs regarding mental health screening. Pediatr Emerg Care. 2007; 23(6):387–393
4.  Betz ME, Sullivan AF, Manton AP, et al. Knowledge, attitudes, and practices of the emergency department providers in the care of suicidal patients. Depression and Anxiety. 2013; 30:1005-12; doi:10.1002/da.22071
5.  Goldenring JM, Rosen DS. Getting into adolescent heads:  an essential update.  Contemporary Pediatrics. 2004; 21:64-90
6. Lyons JS. Communimetrics: A Communication Theory of Measurement in Human Service Settings. London New York: Springer; 2009.
7. Cappelli M, Gray C, Zemek R, et al. The HEADS-ED: A rapid mental health screening tool for pediatric patients in the Emergency Department. Pediatrics. 2012; 130(2):130:e321-e327
8. Cappelli, M., Zemek, R., Polihronis, C., Thibedeau, N.R., Kennedy, A., Gray, C., Jabbour, M., Reid, S., Cloutier, P. (Accepted, Jan 2017).  Evaluating the HEADS-ED:  A brief, action oriented, clinically intuitive, pediatric mental health screening tool. Pediatric Emergency Care.
9. Michie S, Johnston M, Abraham C, et al. “Psychological Theory” Group. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14:26–33.
10. MacWilliams K, Curran J, Racek J, et al. Barriers and facilitators to implementing the HEADS-ED: a rapid screening tool for pediatric patients in emergency departments. Pediatr Emerg Car; 2016.  doi:10.1097/PEC.0000000000000651
11.  ClinicalTrials.gov. Improving transitions in care for children and youth with mental health concerns. Available at:  https://clinicaltrials.gov/ct2/show/NCT02590302 Updated 2015. Accessed March 18, 2016.

Adaptation of the CANS and ANSA in Russia

by: Svetlana G Klimanova, M.S.
Contact Svetlana, svetlanagk@mail.ru
*5/8/2017 Update*

Following a great question from one of our followers, Svetlana provided the following articles as additional resources on adapting the CANS and ANSA for Russian implementation.

 

______________________________________________

The Adult Needs and Strengths Assessment (ANSA) and the Child and Adolescent Needs and Strengths (CANS) tools are two of the Transformational Collaborative Outcomes Management (TCOM) tools that are currently being adapted for use in Russia by a workgroup from St. Petersburg Bekhterev Psychoneurological Research Institute (St. Petersburg, Russia). The need for adaptation of the TCOM tools stem from the lack of assessment tools in the Russian language that comprehensively measure individual functioning; in other words, view psychological difficulties in a social and cultural context and include action items that allow for development of treatment recommendations. Treatment planning and implementation of psychological interventions in the past were based on the results of traditional psychological assessments; there are no comparable frameworks or guideline for development of comprehensive psychosocial treatment planning available in the Russian language.

The CANS has undergone forward and back translation, while the ANSA is at the forward translation stage. In the next phase, Russia is preparing to conduct the pre-testing of the ANSA in a group of adult patients undergoing treatment for substance use disorders. Russia is also planning to introduce the TCOM tools to professionals in social field by presenting at a local conferences and publications in different peer reviewed journals.

There are several challenges that our group in Russia has encountered in the process of translating CANS and ANSA. One of the issues is to adjust items to match characteristics of Russian social context. As an example, we have modified and/or removed some items from “Job Functioning”, “School Functioning”, “Religious/Spiritual”, and “Community Life” sections in CANS to reflect certain characteristics of Russian societal structure. We are planning to further review the items following the results of the pre-testing stage.

Another challenge that we anticipate is an organizational one. Introducing CANS and ANSA in organizations will imply certain changes in models of collaboration between professionals. There are no established evidence-based and/or team-based approaches to treatments in Russia at this point; therefore, the implementation of the CANS and ANSA will bring the need for certain organizational changes which may incur some resistance.

Svetlana G. Klimanova, M.S.
Junior Researcher
Mental Health Therapist
Department of Addictions
St. Petersburg Bekhterev Psychoneurological Research Institute
(St. Petersburg, Russia)


See below for the original post written in Russian

Адаптация инструментов CANS и ANSA в России.

В настоящее время на отделении лечения зависимостей ФГБУ НИПНИ им. Бехтерева (Санкт-Петербург, Россия) проводится работа над адаптацией методик CANS и ANSA для использования в России. В отечественной социально-психологической работе обычно прибегают к использованию методов психологической диагностики с целью постановки дифференциального диагноза и разработки рекомендаций к лечению. В отличие от традиционной психодиагностики, Коммьюниметрические инструменты (Communimetrics) позволяют оценивать психосоциальное функционирования пациентов с учетом социальных и культуральных факторов, а также включают вопросы-действия (action items), позволяющие разработать конкретные рекомендации. В данный момент, русскоязычных аналогов коммьюниметрических методик, позволяющих разрабатывать комплексных психосоциальный подход к работе с пациентами, не существует.

На данном этапе, методика CANS прошла прямой и обратный перевод, ANSA – в процессе прямого перевода. Следующий этап работы – подготовка к проведению предварительного тестирования (pre-testing) ANSA в группе пациентов, проходящих лечение от зависимости от психоактивных веществ. С целью ознакомления психологов и социальных работников с Коммьюниметрическими инструментами, мы также планируем представить информацию о данном подходе на конференциях и в ряде публикаций.

Наиболее сложными разделами для адаптации методик CANS и ANSA оказались вопросы, касающиеся различных аспектов социального функционирования. Например, при прямом и обратном переводе CANS мы модифицировали разделы «Трудоустройство» (Job Functioning), «Духовность и Религиозность» (Spiritual/Religious), «Общественная жизнь» (Community Life), а также вопросы, касающиеся школьного функционирования (School Functioning). Дальнейшее редактирование разделов будет проходить в процессе предварительного тестирования.

В настоящее время, доказательные методы работы в психологии и социальной работе, включая коллаборативные подходы, находятся в процессе развития. CANS и ANSA могут стать основной для разработки более эффективных интервенций, включая модели междисциплинарного взаимодействия. При этом, внедрение CANS и ANSA в работу организаций, может потребовать некоторых изменений на организационном уровне, что может вызвать некоторое сопротивление.

Климанова Светлана Георгиевна,
Младший научный сотрудник
Клинический психолог
Отделение лечения зависимостей
ФГБУ НИПНИ им. Бехтерева (Санкт-Петербург, Россия).

What’s So Hard about Hope?

First published on Dr. Toni Heineman’s blog, we shed a light on one of the most important factors in supporting the needs of some of our most vulnerable children and youth.

OPTIMISM

Optimis.png

Optimism is an item that is present in some versions of the CANS and ANSA. The root of this item is to identify how the individual pictures their future, or if they can at all. As we go through primary school, we plan for secondary, and then even college, and maybe our first jobs. If planning is so engrained in our society, why is hope so hard to create? What drives it and how do you build it? Dr. Heineman addresses those questions in her post (added below).

To view the original post, click on the title below.

What’s So Hard about Hope?

by Dr. Toni Heineman, A Home Within

Our sense of optimism and the capacity to hope are rooted in the first months of life. When infants are fed when they are hungry, comforted when they are distressed, changed when they are wet or soiled, gently rocked to sleep when they are tired, and greeted with a smile when they awaken, they learn that the world is a pretty good place. Fortunately, the world just needs to be “good enough,” because, of course, not every day or night is smooth, there are no perfect parents, and babies are not equally responsive.

When babies’ needs are met day after day, month after month, they get progressively better at letting people know what they want or need. In turn, their parents and other caregivers become better at reading their increasingly subtle signals.

Optimistic children have a sense of confidence about the future. Because they trust that the world will treat them well, they are not afraid to hope and dream. They are also not afraid to work hard to get what they want. When their plans fail—when their hopes are dashed—they have the confidence to pick themselves up and try again.
When life does not begin so well, babies do not learn to hope. If their needs and wants are ignored or their care is misguided, they do not develop a sense of confidence that the world will care well for them. They become pessimistic about the future. They have no reason to hope that things will improve or that tomorrow or next week will be brighter. Without the expectation that their efforts will be rewarded, children do not learn to plan for ways to get their needs met and to work hard for what they want and need.

Sadly, life often does not begin well for children in the foster care system. For many complicated reasons—some stemming from the environment, such as poverty, or homelessness; some arising from the individual, such as mental and physical illness, or addiction—their parents are unable to care for them. Some infants are placed with a family who will eventually adopt them and give them the kind of consistent loving care that allows them to build confidence and learn to hope. Others are not so lucky; they are moved from one home to another, often with periodic stays with their biological parents, in the futile hope that the family can be permanently reunited.

When children’s earliest lives are filled with uncertainty and inconsistent care, they shut down, withdrawing into themselves rather than exploring the world or reaching out for help. They become emotionally numb and fearful of relationships. After all, what is the point of hoping if you are certain that you will be disappointed?

So many of the foster youth who are referred to A Home Within for psychotherapy enter their therapists’ offices too scared to hope that this relationship might be different. Some children approach therapy angrily, actually or virtually challenging their therapists to leave them alone. This anger usually masks fear—better to push someone away than to hope for help and be left behind once again. Others don’t engage because they are convinced that this therapist will leave just like all the rest; others are silent because they are afraid to believe that this therapist might really listen.

Human beings are fundamentally social animals who, at the deepest level, crave relationships, even if it takes a very long time to transform fear into hope. One of our therapists told us about her beginning work with “Rosa,” who came regularly to her weekly sessions, even though it took nearly ten months before she found the courage to make steady eye contact and begin meaningful conversations. Fortunately for Rosa, her therapist ignored a colleague who suggested that she should end treatment after a few weeks because Rosa wasn’t making progress. Instead she followed the original mission statement of A Home Within, determined to be available “for as long as it takes.”

The therapists who volunteer their time through A Home Within are wonderful and generous people who offer many things to foster youth—patience, thoughtful listening, caring, stability, and kindness, just to begin the list. They also know how very, very frightening it can be to trust enough to begin to hope. They keep hope alive for children who are too scared to hold hope for themselves.

For a moment of sheer delight, watch Crosslyn, who captures the essence of hopeful determination. https://www.youtube.com/watch?v=tKpkgCcYtcM

The Growing TCOM Team

Happy Presidents’ Day! In the United States, the third Monday of February is known as Presidents’ Day, which historically honors the first President of the United States, George Washington. Today, Presidents’ Day is commonly viewed as a day to celebrate all presidents – past, present and future. 

Today at the Praed Foundation and Chapin Hall at the University of Chicago we choose to honor our Team members. When we use the term “Team,” we think in broad and inclusive terms, starting with Dr. John S. Lyons, spearheading the Communimetric Theory, to TCOM Implementations all over the world, to the collaborative (including all of you readers) and to our team here at Chapin Hall.

conference-team

Left to Right: Dr. John S Lyons, Lauren Schmidt, Nate Israel, April Fernando, Mark Lardner, Michelle Fernando, Nick Mader, Katie Sun, Anne Farrell, Lynn Steiner.                                     (Not Pictured: Suzie Button)

If you were able to attend the 12th Annual TCOM Conference in Princeton, NJ last year, you probably met most of us. Let’s welcome our newest member of the TCOM Team, Danijela Zlatevski!


Danijela has spent most of her career working to promote equity in the quality of services provided to culturally and socioeconomically diverse children, youth and families in San Francisco.  Specifically, her work at the Parent Training Institute in San Francisco focused on the implementation and evaluation of an evidence-based positive parenting program (Triple P) in community agencies.   Much of her work involved providing technical assistance to intervention practitioners, quality management (fidelity monitoring), and data management and feedback.  Danijela has joined the team as a consultant on the WISe initiative in Washington State to provide support around the use of the CANS and the CANS data system.

Danijela earned her B.S. in Chemical Engineering from the University of Michigan, and her master’s and doctorate in clinical psychology from Wayne State University (Detroit, Michigan).  Her pre-doctoral training included implementing interventions and conducting assessments in school and clinical settings with children and families.

dani

Danijela is based out of Seattle, Washington, so stop by and say HI if you are ever in the area!

To learn more about the growing TCOM Team, visit the Praed Foundation site (www.praedfoundation.org) and join us at the 13th Annual TCOM Conference in San Antonio, TX on November 4-6, 2017. Remember, Proposalsfor next year’s conference are due March 15. Send submissions to April Fernando at afernando@chapinhall.org

Get to know us and let us know how we can better help the work you do!

Communimetrics Roundtable

By Dan Warner, Ph.D.
  • Are you a Communimetrics data nerd?
  • Do you worry about your CANS’ data integrity and database structure?
  • Perhaps you find yourself drifting off into thoughts about data capture, storage, security, and analysis! (oy, the list goes on…).
  • Or maybe you’re more on the statistical and display side: trying to identify norms and populations within your own data, and learn what other techniques are being used by other nerds, just like you, out there in some other social service agency?

Well if so, we have the support group for you!  We are starting a Communimetric Data Roundtable.  This quarterly phone meeting will provide a venue for those who work with CANS, ANSA, FAST, or any other such data, to learn about what others in the field are doing with this work, and give opportunities for all of us to share and get feedback.  Our goal is to have each session be focused on one or two topics, with opportunities for discussion and questions.

My name is Dan Warner, Ph.D., and I am the executive director of Community Data Roundtable, a nonprofit organization dedicated to advancing a data-driven social services system.  Our organization strongly endorses Communimetric methods because of their demonstrated power in measuring meaningful information at the individual and system level, while also quickly making that information actionable at those same two levels.  I personally believe much of this power comes from the way the tools bind the commitments of those that use them.  Be it the family and treatment providers as they discuss the CANS while planning treatment, or the managed care entity and advocacy groups as they review system planning initiatives – Communimetrics works because people come together to score and understand it.

The quarterly roundtable is meant to build such communication amongst those of us who work on the “back end” of TCOM projects.  Upcoming planned topics include: review of different outcomes metrics for Communimetrics, an introduction to Communimetrics generally, and a few groups with larger projects want to share some of their preliminary findings.   The spirit of the group is one of openness and sharing.  This is not a place where people need to share finished work that is ready for publication, or to go live in some system.  Instead, it is a place where people are invited to be creative, share open questions, and get feedback on hunches and ideas.  We hope that such an environment will encourage creativity and robust growth for Communimetric science throughout the social services and scientific field.


Anyone interested in joining should email dwarner@communitydataroundtable.org with a request.  Please let me know your professional background and relationship to communimetric data work in the email.  Likewise, if you have an idea for a topic of discussion, or would like to present, please email me at the same address.

Healthy Relationships

Happy Valentine’s Day!

What does Valentine’s Day mean to you? Is it a celebration of love, a hallmark holiday, or both?

As a child, this holiday can take the form of a classroom activity where you put Valentine’s Day grams with chocolates and hand them out to each child in the class. As we get older we can celebrate this holiday with friends (Pal-entine’s/Gal-entine’s day), family, and/or a significant other by sharing gifts or other displays of affection. Harvard University conducted a study on how our social connections have the power to not only give us pleasure, but to influence our long-term health in ways just as powerful as exercise, diet, and sleep.  One study, which examined data from more than 309,000 people, found that lack of strong relationships increased the risk of premature death from all causes by 50% — an effect on mortality risk roughly comparable to smoking up to 15 cigarettes a day, and greater than the risk from obesity and physical inactivity.[1]

Relationships can be healthy or unhealthy. Healthy relationships aren’t perfect, but they are fun and make you feel good about yourself. Unhealthy relationships can cause discomfort and even mental and physical harm. Unfortunately, the statistics on unhealthy relationships are alarmingly high. The National Council on Crime and Delinquency found that 1 of 3 girls in the US is a victim of physical, emotional, or verbal abuse from a partner. The long-lasting effects of being in unhealthy relationships as a youth lead to higher risks of substance abuse and other risky behaviors.

In some adaptations of the CANS, there are specific items geared towards those transitioning to adulthood or Transition Age Youth (TAY); that is, items to be completed for young people typically ages 16-21. These items include Job Functioning, Independent Living Skills, and Educational Attainment. In the Life Functioning Domain of the Illinois Medicaid-CANS, the Intimate Relationships item is used to rate the youth’s current status in terms of romantic/intimate relationships. Some questions to consider for this item include:

  • Is the youth in a romantic partnership/relationship at this time?
  • What is the quality of this relationship?
  • Does the youth see the relationship as a source of comfort/strength or distress/conflict?

0. Adaptive partner relationship.  Youth has a strong, positive, partner relationship.

1. Mostly adaptive partner relationship.  Youth has a generally positive partner relationship.

2. Limited adaptive partner relationship.  Youth is currently not involved in any partner relationship.

3. Significant difficulties with partner relationships.  Youth is currently involved in a negative, unhealthy relationship.


While a helpful item, many users struggle with rating it:  How do you rate this item if the youth is not currently involved in an intimate relationship? Remember that rating items is a collaborative process that involves the young person’s input. If the youth is not in an intimate relationship and is not interested in being in one, then this is not a need and can be rated ‘0’. If, however, the youth is not in an intimate relationship but IS interested in having one, then the item can be rated as a need.

This item is just as much about perspective as it is about physical and emotional health and one’s on-going development. In healthy, intimate relationships, a person can fully develop to his or her potential,, while unhealthy intimate relationships can cause physical and emotional,  suffering, and become barriers to one’s development.  It is important to understand how a person functions within relationships, in order to fully understand one’s sense of self and how he or she uses that self understanding in relating to others – be it friendships, family bonds, and interacting with others as part of everyday life.  Relationships can be the context that motivates individuals to organize their sense of identity and meaning, and achieve a sense of coherence and continuity.

On this Valentine’s Day, let’s celebrate the good people in our lives, regardless of whether they are romantic partners, family or friends. Happy Valentine’s Day from all of us on the TCOM team!


[1] Harvard Health Publications. (2010, December). The Health Benefits of Strong Relationships. Retrieved February 13, 2017, from http://www.health.harvard.edu/newsletter_article/the-health-benefits-of-strong-relationships

TCOM’s Targeted Tools

The TCOM Team met in Chicago in January to kick off the New Year and review the work being done across the collaborative. As a result of this meeting we’ve produced our very first TCOM newsletter that highlights these efforts! *Keep an eye out for the release of our newsletter next week!*

One important discussion at our team meeting was the use of the TCOM Tools and the targeted audience.  While all derived from Communimetrics, there are clear distinctions in the focus of our tools as noted in their titles:  Child and Adolescent Needs and Strengths (CANS), Adult Needs and Strengths Assessment (ANSA), Family Advocacy and Support Tool (FAST), and Crisis Assessment Tool (CAT).  Most experienced users know the importance of appropriately using these tools to match the circumstance , target audience or population.  Thus, the ANSA is most appropriately used with adults, the FAST with families, the CAT for crisis situations, and so on.

So, WHY DO AGE AND DEVELOPMENT MATTER?

For providers working with individuals across the lifespan, the selection of the appropriate TCOM Tool can have particular significance.  Beyond the distinction between children, adults and families as the focus of care, there may be different age groups, developmental issues, or specific populations that should be kept in mind.  The CANS, for example, has versions targeted to specific age groups, for example, 0-4, 5-17, and even 18-24.  In some jurisdictions, the CANS covers ages 0-21 (sometimes up to 24) with specific age-related modules for children ages 0-5 and youth or young adults ages 16-24.  A few examples of items that are specific to age ranges include PICA, Failure to Thrive (for young children) and Career Aspirations, Arrests, and Job Performance (for older youth).

Even items that are rooted in the same action are inherently different when considering the developmental difference between a young child and youth.  Taken from the same CANS version, below are two items that reference a common behavior. For children between the ages of 3 and 6, the Flight Risk item specifically refers to behaviors that can be a precursor to behaviors and actions in that of an older child.

FlightRisk.png

For youth 6 years and older, however, the Runaway item should be completed. This item expands upon the Flight Risk item to account for developmental differences and experiences of an older child or youth. Flight Risk focuses on behaviors of escaping and bolting, whereas Runaway focuses on whether or not youth are running away and the risks associated to where they are going.

runaway

In the version of the CANS where this particular item is used, a rating of 1, 2, or 3 would trigger the Runaway Module that provides additional information on the young person’s runaway behavior.

There are CANS versions specific to populations of youth, such as:  Commercially Sexually Exploited (CANS-CSE), and the Autism Spectrum Profile (CANS-ASP). Some items present in the CANS-CSE include Duration of Exploitation, Age at Onset, and Trauma Bonding/Stockholm Syndrome. In the CANS-ASP, you will find items such as Repetitive Behaviors, Speech Articulation, and Stereotyped Verbal Output.  Ultimately, we need to recognize the importance of matching the TCOM Tool to the audience in order to best capture the needs and strengths of the individual and family and develop the most appropriate strategies for care.

THE BREADTH AND DEPTH OF THE TOOLS

The TCOM Tools cover the breadth needed to impact the largest range of the population.  The tools are free to use and have been researched and proven to be a reliable and valid way to assess the needs and strengths of a wide range of the population. Yet the tools are limited, as you can see, by version-specific age ranges and populations. It is of utmost importance to recognize and pay attention to the specific tool you are using to assess the child/youth/adult/family or specialized population in order to have meaningful information that translates into identifying the most effective solutions.

The Women’s March-January 21, 2017

by Suzanne Button

darkness

Two women meet at their child’s school. Mothers and daughters become and stay friends, even though one family moves far away– from Alaska to Virginia. This longstanding social connection leads, through a series of other social connections, to 21 women, ranging in age from 9 to 93, spending the weekend marching in Washington, D.C., along with many others who stood up and marched for unity, connection and caring.

The march itself sprung up out of a longing for social and interpersonal connection and their potential to ameliorate societal fracturing.  One woman in Hawaii woke up after the Presidential election in November and pondered how our country might respond to polarized rhetoric by calling upon the strength of its women.  She created a social media page focused on bringing together women from across the country to march on Washington D.C.   She envisioned the march as expression of solidarity, unity, and caring with and among communities of women and all other groups who face marginalization and are vulnerable to discriminatory action.  Quickly, people from many communities across the world responded to her call for unity.  Through a network of postcards, social media messaging, and even the knitting and sharing of pink pussy hats, Pussy Hat Project, led to sister marches across the country and around the world.

The 20 women that I was with on Saturday were just a few of the estimated 500,000 people marching in Washington, and of the many more marching across