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Helen M. Midouhas, M.S. Ed., L.P.C. FFT LLC. Such as: ◦ Core elements needed for long-term sustainability ◦ Implementation elements that are constants.

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Presentation on theme: "Helen M. Midouhas, M.S. Ed., L.P.C. FFT LLC. Such as: ◦ Core elements needed for long-term sustainability ◦ Implementation elements that are constants."— Presentation transcript:

1 Helen M. Midouhas, M.S. Ed., L.P.C. FFT LLC

2 Such as: ◦ Core elements needed for long-term sustainability ◦ Implementation elements that are constants (firm) and elements that are flexible to unique agency characteristics ◦ Surprising (and not surprising) findings

3  1. Participants will be able to list at least 3 “ingredients” needed for a sustainable EBP  2. Participants will be able to describe the relationship between fidelity and outcomes  3. Participants will be able to discuss ways to enhance current programming in at least one of the following domains: data collection, staff retention, referral process, monitoring

4 Functional Family Therapy Integrated / Research Proven Model Behavior problem or at risk youth/families Age range: Short term intervention Average of sessions Average between 3-6 months Service Delivery Contexts Juvenile Justice Mental Health Child Welfare / Social Services

5 330 sites in 14 countries and most US states 50,000 families served per year 2,500 Therapists Dissemination sites that are now 15 years out in the implementation Multiple Settings Rural: Kansas, Iowa, Missouri, Wisconsin, Eastern WA, etc Urban: NYC, Los Angeles, Kansas City, Denver, Minneapolis, etc. Juvenile Justice Child Welfare Mental Health School Statewide/Nationwide Projects Washington, Pennsylvania, DC, Florida, Norway, Netherlandsds, California, Maryland

6 Super Summary of the FFT Model and “FFT Attitude:” - A Philosophy / Belief System about people which includes a core attitude of Respectfulness; of individual difference, culture, ethnicity, family form - A family focused intervention involving alliance and involvement with all family members (Balanced alliance) with therapists who do not “take sides and who avoid being judgmental. - A change model that is focused on risk and (especially) protective factors – “Strength Based”” - With interventions that are specific & individualized for the unique challenges, diverse qualities, and strengths (cultural, personal, experiential, family forms) of all families and family members. - And an overriding Relational (versus individual problem) focus

7 Core Elements Respect- based Integrated/ Multisystemic Data DrivenPhase-Based Copyright FFT LLC 2012

8 GENERALIZATION BEHAVIOR CHANGE SESSIONS PRETREATMENTPRETREATMENT POSTTREATMENTPOSTTREATMENT MOTIVATION Relational Assessment ENGAGMENTENGAGMENT MOTIVATION

9  Outcome Studies ◦ 25-60% reductions in recidivism ◦ RTCs and Effectiveness studies ◦ Sustainable effects, demonstrated repeatedly From 1 – 5 years after intervention 3 Yr follow up prevention effects for siblings Positive effects on parent/adult mental health  Improved retention/lower dropout ◦ Child Welfare—39% reduction in out of home placement and decreased units of service by half ◦ Family functioning improvement ◦ Cost Benefits (as of 2013)  $18.98 saved for every $1 invested  $61,370 benefits vs. $3,261 costs per case

10 Hillcrest Children & Family Center First Home Care Implemented in Fall 2010, as of 2014, 25+ therapists providing FFT in D.C. FY FFT had an 70% successful closure rate with over 250 youth and families served 90% or higher rate for ultimate outcomes PASS

11  Gathered data from 46 teams that have been successfully implementing FFT 7+ years  Respondents were team leads or administrators  Question domains: ◦ Team (therapists, supervisors) ◦ Referrals ◦ Funding ◦ Agency/Organization (culture, incentives, support) ◦ Data utility

12  Last three years site 1.7% of sites closed. ◦ Extremely low referrals  Little relationship with referral source ◦ State level changes/re-bidding or program changes  During last five years lost 3.8% of sites  96% retention

13  While we might have in some cases accidentally done things that lead to FFT being sustained in a community, sustainability is not an accident.  How we begin has everything to do with where we end up  While we heavily emphasize information on outcomes with families, data on youth/family change is even more important to sustainability than we thought.  Regardless…Implementation (or “putting into effect”) has an ongoing nature. ◦ No program in practical terms reaches stasis (some equilibrium that doesn’t require attention). Service systems, therapists, teams, organizations are too dynamic.

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15  Replicate therapist practice in evaluations and thus replicate the outcomes of those evaluations at community sites. Or adherence. ◦ “Train, evaluate, close project” VERSUS lasting practice change that achieves consistent outcomes. FFT LLC creates apparatus to support ongoing fidelity…  Training and consultation protocol  Monitoring, assessing, and correcting practice via assessment and web based protocol  Creating internal infrastructure to do this

16 * Statistically significant outcome as compared to the control condition Washington State Institute for Public Policy, 2002 N=980 38% reduction in felony crime 50% reduction in violent crime $18.98 return for each $1 invested $2100 per family cost to implement

17 Learning from WA state: fidelity = outcomes A lot of pressure so that by 2007 such an emphasis on the methods to understand/assess practice became an overemphasis  Losing the central fact that fidelity IS actual practice ◦ Example: a good behavior change progress note is different (though perhaps linked) to doing an excellent behavior change session/s.  Separate clinical adherence from dissemination adherence. Dissemination adherence may help us understand clinical fidelity but it’s not the same thing. Fidelity part two

18 SUSTAINABILITY  The context in which therapists operate and are supported doesn’t just impact but ALLOWS fidelity (outcomes) and sustainability  ◦ focus on creating a welcoming “noise-free” environment for FFT practice

19  Increasing focus on state/nationwide support and data systems for FFT (i.e. CA, FL, PA, MD, Wash DC, WA, Maine, Norway, NL)  Increased focus on providing aggregate data and focused QI data  Community Development Team process in CA retain 45 out of 50 sites over 11 years  Increased experimentation with complimentary case management systems (FFP) to create a more supportive context  Diversify funding (medicaid)  A word about Medicaid: it can help, or erode, or take us off model…it depends which state you operate in

20  Simply understand dissemination better ◦ Highly skilled consultants and trainers  Avg of 9.6 years experience in doing FFT, supervising, consulting with other sites, and training  Work at and are selected from the  Staff dedicated to funding issues, particularly Medicaid  Always clinically grounded by Jim Alexander and Mike Robbins ◦ Increasingly organized statewide systems  Stronger and more responsive use of data ◦ With therapists, teams, multiple teams, states and nations ◦ All without losing clinical responsiveness ◦ Addition of Behavior change modules fitted to FFT

21  Implementation targets: therapists, agency, referral/funders  Lay groundwork for sites “owning” the responsibility for their program from the beginning ◦ Transparency, about opportunities AND challenges ◦ Sites set up decisions within a range of choices ◦ Increasing role of local site in guiding fidelity/practice, with FFT taking steps back as local infrastructure/outcomes grow  In some ways early implementation is an attempt to buy time for the local FFT project to create ◦ Enthusiastic, credible and well skilled FFT therapists, supervisors, and programs ◦ To develop FFT outcomes to share with funders, referral sources, the agency and the community

22  Agency understanding and support of FFT clinical practice, philosophy, data and QI ◦ Clinician and team choices  Referrals—appropriate and reliable ◦ Critical in first 6 mos, and in forging clinician practice (WA state data)  Solid history of or commitment to relationships with funders and referral systems  Creating multiple feedback loops (between FFT team, Training, Agency, Larger systems)

23 ◦ Critical throughout but particularly in first year ◦ Referral systems/agent that understand FFT and operate in ways that support the FFT practice  Working with families  Completion based on FFT model  Not saturating families with too many referrals alongside FFT (or ones that work against FFT).  Appropriate and ample #s referrals ◦ More families  more opportunities to apply FFT  more opportunities for success  builds confidence and motivates

24  Regardless of type of agency, location and families served, these elements are crucial: ◦ Administrative support of EBP, FFT, the team ◦ Positive relationship with community partners  Champions in the agency and community  Routine meetings and open communication ◦ Sufficient referrals for full utilization ◦ Referrals that are appropriate ◦ Hiring practices and job expectations specifically tailored to implementing FFT ◦ Embracing and utilizing QA practices & feedback

25  Almost 90% MA level or higher  92% have caseloads between  Almost 80% of supervisors carry caseloads of 3 to 10, with 26% carrying btw 7 and 10  78% have team sizes between 3 and 5 therapists  Equal number of full and part time therapists, but only one team with just part time therapists

26  Top therapist characteristics to create a lasting program ◦ Confidence (85%) ◦ Flexibility with schedule (77%) ◦ Experience with home-based services (36%) ◦ New to the field (25%) ◦ High experienced therapists (18%) ◦ Experience with EBTs (12%)  84% have specific job hiring practices and  75% have specific FFT job descriptions

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29  While less than 20% provide specific incentives for strong FFT performance, over 80% engage in FFT team building activities  Over 90% of agencies express a strong commitment to EBPs  78% provide other EBPs—they are not just FFT but believers in EBPs

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32  Trainings  Retreats  Outings ·  B’day and team anniversary lunches  Team dinners  Awards breakfasts ·  Common team offices  Flexible schedules  Wellness activities  Allowing for conference attendance and sharing with team members  Statewide trainings

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35  Multiple funding sources  Smaller teams (3-5 members)  Combination of primarily FTE and some PTE  Not providing financial incentives  But providing ample methods to promote positive team culture ◦ Flexible schedules, team outings/retreats, celebration meals, recognitions by and in meetings, focus on personal wellness, allowing for ongoing training for licensure

36  Teams comprised of all PTE  Large teams (6-8 therapists)  Single funding sources  BA level team members  Small caseloads (5-7 families)  Single referral types

37  Being purposeful in determining how the flexible elements can be tailored to unique implementation needs of each agency may be key to long-term success  Flexibility allows teams to weather the storms of funding changes, referral changes, agency changes

38  First Home Care, Hillcrest, PASS  Brendalan Jackson, FFT Site Supervisor  Taleisha Ellerbe, FFT Site Supervisor  Stephanie Sanders, FFT Clinical Supervisor  All three sites compare favorably with national study results, each will highlight a area of the study and how it is working for them.

39  Agency overview  Program overview  - Years in FFT and Phase of Team  - Make up of team (FT, PT, caseloads)  -Target population  -Structure of your program  -Your role in the program  -Insights, thoughts, experience as a EBP

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41  Quality of team and Agency support

42  Agency overview  Program overview  - Years in FFT and Phase of Team  - Make up of team (FT, PT, caseloads)  -Target population  -Structure of your program  -Your role in the program  -Insights, thoughts, experience as a EBP

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45  Agency overview  Program overview  - Years in FFT and Phase of Team  - Make up of team (FT, PT, caseloads)  -Target population  -Structure of your program  -Your role in the program  -Insights, thoughts, experience as a EBP

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47  Referral and community support

48  Along with constants… ◦ Ample referrals ◦ Well-trained, positive and strong FFT supervisor ◦ Positive team culture ◦ Funding ◦ Agency support  There are elements that are necessary but can be integrated to unique agency with flexibility ◦ Team: employees that are all FTE or FTE & PTE ◦ Team size: larger or smaller ◦ Funding sources: multiple or single ◦ Support: financial incentives or team culture

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50  Helen M. Midouhas, M.S. Ed., L.P.C.  Stephanie Sanders, M.A., L.P.C. Brendalan Jackson,


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