How is Implementation of the CANS Outside of the U.S? – featuring Mother’s Choice in Hong Kong

by: Lea Wong and Saw Han Quah

Recognizing the valuable TCOM work that is being engaged in around the world, we are excited to announce a quarterly blog series that will focus on implementation in different countries. These posts will provide information on implementation considerations, challenges and learning opportunities, and will give a peek into how places outside of the United States are using the TCOM tools.

We begin this series with an implementation of the Child and Adolescent Needs and Strengths (CANS) in its early stages in Hong Kong by Mother’s Choice, a local charity serving children without families and pregnant teenagers. The following is an interview with Dr. Saw Han Quah, Clinical Psychologist in private practice in Singapore, and Lea Wong, MA, Assistant Director, Children Services at Mother’s Choice, in which they discuss their efforts to implement the CANS.

Question: Praed (P): What TCOM tool(s) are you using?

Answer: Lea Wong (LW): Since 2018, Mother’s Choice has implemented the CANS adapting it to the Hong Kong context. Our vision is to see every child in a loving family, and our mission is to join hands with our community to give hope and change the life stories of vulnerable girls and babies.  We support three main target clients:

• Children in care: At Mother’s Choice, we run a Child Care Home for children aged 0-6 years and foster care services for children aged 0-18.
• Youth: Girls facing crisis pregnancy, and those who may be at risk of facing crisis pregnancy (primary & secondary school students).
• Families: Foster families, adoptive families, and struggling birth families.

To date, we have integrated the CANS reporting tool in our service delivery and case management for children and youth.

P: Why did you decide to use this tool?

LW: Every day, as social workers, we have the privilege to hear and witness the life stories of our vulnerable clients. As they share their experiences and seek help, we, along with multiple professionals, retell parts of their stories, based on our specific skills and focus. Case Management at Mother’s Choice is a collaborative process of assessment, planning, care coordination, intervention, and advocacy to meet a child and their family’s needs, all working towards placing that child in a safe, permanent, loving family as soon as possible. We take a holistic and shared approach to each case: social workers, medical professionals, supervisors all work in partnership towards a shared vision for the child.  Our case management framework needed this tool to reliably and succinctly communicate a client’s status, the focus of care and the level of intervention needed, enabling us to monitor our client’s needs and the impact of our interventions.

At the agency level we also needed to monitor our programs, their impact, and their outcomes in a systematic and consistent way, using evidenced based data and best practices to review our program design and performance, in order to drive continuous improvement in our services.

Our Deputy COO Helene Rao stumbled upon the CANS tool whilst researching IT solutions for a case management system. We were fortunate enough to hear more about the IT transformation and the use of CANS from the Casey Foundation, which then led us to speaking with Dr John Lyons. We had explored many different assessment tools to measure the all-rounded needs of our clients aged from 0 to 25 years. CANS and its standardized scale to collate information reliably on needs and strengths of a client gave us a clear framework to streamline our processes and flow of information.

The change management that followed was no small feat! Most of our team was a little sceptical and overwhelmed at first, but we were very fortunate to partner with Dr Saw Han Quah who had the rich experience of going through a similar process in Singapore. As Saw Han made regular trips to Hong Kong to see her family, she very kindly and patiently sat with us to map out the next steps!

P: How are you implementing the CANS?

LW: We spent around a year researching on CANS, dialoguing and evaluating our readiness so as to ensure that this was the right tool for our agency. We then mapped out an implementation plan, starting with the contextualization process for its use in Hong Kong.

Dr Saw Han Quah was invaluable in this process. Introduced to us by Dr Lyons, we leaned on  Saw Han’s rich experience as a clinical psychologist in the Ministry of Social and Family Development from 2010 to 2015 tasked with implementing the CANS and FAST.  Singapore was the first Asian country to have adapted and implemented the CANS. Together, we discussed and refined the definitions of our CANS items taking into consideration the similarities in culture between Hong Kong and Singapore. Mother’s Choice contextualized a 0-6 years old version and a 7-25 years old version of the CANS manual based on our client profile and services nature, including modules for pregnant and parenting teens.

We first embedded the use of CANS into our case management processes for children aged 0 to 6 years placed in our child care home and foster care. Their individual baseline CANS is completed within 90 days after admission and every 3 to 6 months thereafter or whenever there is a significant change.  Using the CANS data collected, we developed an algorithm to measure the complexity and intensity of cases which helps to inform our casework decisions, the level of care needed to provide targeted services. This first rollout required initial training and coaching to our team of social workers as well as ongoing workshops and reviews to ensure a consistent and reliable use of the tool to drive treatment planning and program design.

The next step was to repeat this process for older children, partnering with our Youth and Pregnant Girls team to address the specific needs of a parenting or pregnant teen. Leveraging our learnings and past experience, the process was a lot quicker! The 7-25 years old CANS has just been endorsed by the Praed Foundation in December 2020.

P: What stage of implementation are you in? How long since you began implementation?

Saw Han Quah (SHQ) and LW: We began in December 2018,  certifying all of Mother’s Choice social workers to use the children aged 0-6 years CANS and have since then rolled out the CANS for all clients aged 7-25 years. Our implementation of the CANS was accompanied by a parallel rollout of the technology tools to manage cases and collect CANS data electronically, so as to facilitate the process. With the systems in place, we are now just beginning on our journey of data analysis and reporting.

P: What barriers have you faced? What would you tell others to prepare for?

SHQ and LW: Colleagues at Mother’s Choice have most often been trained in the use of psychometric tools, and the CANS, being a communimetric tool, required time, training and regular reviews of case studies to fully understand its application in our services beyond the theory.

Our work relies heavily on communicating our vision for clients with a large stakeholder group, including clients and their family members, professionals from the government and other community agencies. Being one of the first agencies in Hong Kong to integrate the CANS into our case management processes, it will take time and effort for us to illustrate to others how the tool can be used by the clients themselves to voice and work towards their aspirations, as well as how it can assist all professionals, not just Mother’s Choice, to reach and measure outcomes.

At Mother’s Choice, we look forward to using the CANS with our families and youth directly. Engaging our youth and families with CANS as the key tool to guide the conversations will be great asset to delivering the best services.

The CANS is the tool that allowed us to implement TCOM as a case management framework. When onboarding such a tool, the organization must be ready to review not only their assessment reporting, but also how they will align these to  case management tactics and models including decision making, service planning, supervision, etc.

P: Have you developed any resources (outside of the reference guide/manual) that might be shareable?

LW: We have developed program logic to measure and monitor the complexity and intensity of cases. This algorithm puts a rating on each case that helps us make decisions on the resources that are needed to manage the cases.

A Chinese translation of the CANS is in progress and we are currently working on setting up a Hong Kong CANS E-learning Certification.

P: What advice would you have for others planning a new implementation?

SHQ and LW: We suggest setting a working group at the beginning of the project that consists of representatives from the frontline, data professionals, IT professionals and management so as to have all stakeholders involved in the design and planning.

Both for the design and the implementation of CANS in your region, we suggest to take an “agile” approach, starting with a shorter list of CANS items first (our suggestion is to start with the Standard CANS Comprehensive). Use Standard items to map out retrospective local cases and analyse how the items fit and sit with front line users, editing and specifying more clearly your item definitions. Work in iterations. From our experience, once the implementation kicks off, new insight and conversations on clinical practices, service delivery gaps, and organization improvement will surface which can then inform the next steps of the implementation plans.

P: Who are your “TCOM Champions” within the system (i.e., those who understand and are eager to use the TCOM framework and the CANS)?

LW: Saw Han is our TCOM champion extraordinaire! She has walked alongside Mother’s Choice all this time with insight, patience and encouragements. She has enabled us to develop our very own TCOM champions amongst our Mother’s Choice colleagues always speaking out the heart and voice of the TCOM principles. We are so grateful for her expertise and consult on this critical project as we advance and refine our clinical use of the tools. We are inspired by her professionalism, enthusiasm and passion in bringing the TCOM tools to Singapore and Hong Kong.

At Mother’s Choice, we strive to implement best practices by modeling small, building up internal capacity, and using that to influence big.

P: What are your future goals with the CANS?

SHQ and LW: In the short-term, we plan to continue to work with the Praed Foundation to build the training tools online in English and Chinese for our Hong Kong CANS to enable efficient recertification for all our users.

At Mother’s Choice, we strive to implement best practices by modeling small, building up internal capacity, and using that to influence big. We want to inspire and equip others to be able to do what we have done. Part of that vision includes integrating the TCOM tools at all levels of our practice so that we can then share these tools with our peer agencies and the Social Welfare Department. This will allow all involved in the care of our clients to all speak a common language, to translate our findings, and turn evidence into actionable and measurable steps with the goal of reaching better outcomes for clients and influencing practice in the long term.

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