1. Orientation to Child and Family Team Practice and the Pennsylvania Youth and Family Institute
Jim Rast, Ph.D.
John VanDenBerg, Ph.D.
December, 2007
Orientation Slides

2. This Pennsylvania Effort…
Pennsylvania has a long history of successful collaboration and programs to support children and their families.
Through the PYFI, VVDB is committed to developing capacity to provide, coach and train sites with a commitment to implementing Child and Family Teams processes (high fidelity wraparound) in PA
VVDB is partnering with the PYFI, participating Counties, and State Level partners to help this transformation succeed
Orientation Slides

3. Wraparound Wraparound and wraparound are not the same thing.
PA uses the term wraparound differently than almost every other state.
Arizona had other uses for the term wraparound and chose to use the term “child and family teams” to describe the process of integration and individualization used at the practice level
Orientation Slides

4. Development of Wraparound
Grassroots Development
General Principles
Applied in many different ways
Creativity and advances
200,000 children in 1999
Initial Results
Life changing success stories
Strong support
Mixed evaluation results
Research shows results match fidelity
Initial results of wraparound included many life changing success stories. These stories were important in creating demand for wraparound for more youth and families. Evaluation results, however, found wraparound compared to other case management programs and other services had mixed results. Sometimes it was better and sometimes not. Further research showed that what was provided and called research varied from program to program and community to community. As the fidelity measures were developed, research began to show that when wraparound had high fidelity to the model it got better outcomes.
Orientation Slides

5. Defining Wraparound Steps to Define Wraparound
Duke meeting on principles
National Wraparound Initiative
Who they are
Process used
Products produced
Wraparound Fidelity Assessment System
The meeting in 2002 was held at Duke University and resulted in a common set of principles for wraparound (paper from this meeting in the supplemental reading section) and development of the initial fidelity tools. In 2003, an advisory committee was formed that consisted of leaders of the wraparound family movement, researchers, leading providers of wraparound and coaches/trainers of the process. This group worked for two years to come to agreement on the principles and phases and activities for high fidelity wraparound. From this, new fidelity tools have been developed.
Orientation Slides

6. Wraparound Process Is a Process for Supporting Youth and Families that
Is defined by 10 principles of how the process is implemented;
Is done in four phases and related activities that describe what is to be done; and
Fits the four components of the theory of change that explains why it works.
Training Tips: It is good to emphasize that wrap is how we actualize the SOC. You may want to page back to the slide on wrap values when you use this one. One of the most common errors is to make wrap into a discrete service rather than a community process. This is a good time to make that point – wrap should be widely woven into all levels of all services and supports in a community.
Orientation Slides

7. Principles for Wraparound
Family Voice and Choice
Team Based
Natural Supports
Collaboration (and Integration)
Community Based
Culturally Competent
Individualized
Strengths Based
Persistence
Outcome Based and Cost Responsible
This slide is typically used to show the core values of the wraparound process. This slide is often individualized to each site’s unique values.
Training Tips: Use the “Formal vs. Informal” exercise with this one to place emphasis on how important the informal resources are. We often commonly use the “Write down your own family culture” exercise with this one to emphasize the culture value.
Orientation Slides

8. Phases and Activities, and Skill Sets
NWI phases and activities
Vroon VanDenBerg specific skill sets for wraparound facilitators, coaches and family support partners
VVDB performance based training and coaching products
Credentialing and Quality Improvement
Used and been in over 35 sites across North America.
Sites using these products report greatly improved outcomes and more satisfied families and staff.
Orientation Slides

9. Impact on CAFAS Scores after 6 Months
Orientation Slides

10. Impact of Fidelity
Orientation Slides

11. Breakdown of Fidelity Scores
Orientation Slides

12. Impact on CAFAS Scores after 18 Months
Orientation Slides

13. The Theory of Change is Is why we do wraparound
Is what about wraparound that makes it work
Is what differentiates it from other service coordination processes
Defines expectations for what we hope to accomplish through wraparound
A theory of change describes why something is expected to work. It begins by clearly stating what is being done and then why this impacts results. The theory of change for wraparound tells us why wraparound works and why it is different from other services and processes. It also sets expectations for what we accomplish with families.
Orientation Slides

14. Why Does Wraparound Work?
Theory of Change for Wraparound
Why Does Wraparound Work?
Self
Efficacy
NEEDS
Efficacy
Natural
Support
System
Integrated Plan
The formal theoretical foundation of the wraparound process builds from Maslow’s (1970) hierarchy of needs, Bandura’s (1977) theory of self-efficacy and Bronfenbrenner’s (1979) theory of human ecology, and integration of plans, services and supports across the family. Simply put the theory of change is:
Meeting the basic needs and strengthening the social networks of children with severe mental health challenges and their families while enhancing their belief they can create a successful future, will result in good or at least improved lives. This will be further enhanced by integrating their services and supports into a single plan of action.
The first component of this theory is identifying the needs that are the most important to the youth and family and focusing efforts in helping them to meet these needs. The second component is helping them to develop and strengthen the natural support networks that can help them meet these needs and sustain them in the future. The third component is helping them to develop the skills and confidence to believe they can do this successfully and continue to do it after the wraparound ends. Families with complex needs often have multiple and competing plans and dozens of service providers and supports. Bringing these together into a single and simplified plan will greatly improve their prognosis of success.
Orientation Slides

15. Why Does Wraparound Work?
Theory of Change for Wraparound
Why Does Wraparound Work?
Self
Efficacy
Wraparound addresses the priority needs identified by the youth and family
NEEDS
Efficacy
Natural
Support
System
Integrated Plan
The first component builds on Maslow’s hierarchy of needs which is often depicted as a pyramid consisting of five levels. The four lower levels are grouped together as deficiency needs, while the top level is termed growth needs. The basic concept is that the higher needs in this hierarchy only come into focus once all the needs that are lower down in the pyramid are mainly or entirely satisfied. Once an individual has moved past a level, those needs will no longer be prioritized. However, if a lower set of needs is continually unmet for an extended period of time, the individual will temporarily re-prioritize those needs – dropping down to that level until those lower needs are reasonably satisfied again. The deficiency needs include:
Physiological needs are the basic needs of the organism to maintain life and consist mainly of food, shelter, and sleep. These physiology needs take the highest priority in motivation and when they are not met it will impact the person’s ability to control thoughts and behaviors, and can cause people to feel sickness, pain, and discomfort.
Safety needs are the second level and describe issues of physical safety and security.
Love/Belonging/Social needs After physiological and safety needs are fulfilled, the third layer of human needs is social. This involves emotionally-based relationships in general, such as: friendship, sexual intimacy, having a supportive and communicative family.
Esteem needs according to Maslow, all humans have a need to be respected, to have self-respect, and to respect others. People need to engage themselves in order to gain recognition and have an activity or activities that give the person a sense of contribution, to feel accepted and self-value, be it in a profession or hobby.
Orientation Slides

16. Families are not Fully Engaged
Research finds that
Up to 60% of families drop out of services before they are finished
Children from vulnerable populations are less likely to stay in treatment
Another challenge—having treatments that work is not the end of the story. Practitioners can not operate under the “build it and they will come” theory…because in fact, often they don’t! And, minority families in particular are less likely to access traditional services.
Not only to most family not access services, 40-60% drop out before they are completed. Furthermore, those from particularly vulnerable populations (e.g., children of single mothers, children living in poverty, minority families) and with the most serious presenting problems and less likely to stay in treatment after the first session.
When asked about reasons for dropping out, families site stressors associated with getting to treatment, a sense that the treatment is irrelevant, and a poor relationships with the therapist.
Although clinicians may sometimes have little control over client’s daily life stressors or difficulties in accessing care, clinicians clearly should have control over the relevance of treatment for the families who seek their services AND over their relationship building with the client. Engaging clients in the treatment process should not be a passive, but active ongoing process!
Orientation Slides

17. The Challenge of Full Family Engagement
Why do families drop out?
Treatment is stressful
Treatment seems irrelevant
Poor relationship with therapist
Concrete obstacles:
Time, transportation, child care, other priorities
Another challenge—having treatments that work is not the end of the story. Practitioners can not operate under the “build it and they will come” theory…because in fact, often they don’t! And, minority families in particular are less likely to access traditional services.
Not only to most family not access services, 40-60% drop out before they are completed. Furthermore, those from particularly vulnerable populations (e.g., children of single mothers, children living in poverty, minority families) and with the most serious presenting problems and less likely to stay in treatment after the first session.
When asked about reasons for dropping out, families site stressors associated with getting to treatment, a sense that the treatment is irrelevant, and a poor relationships with the therapist.
Although clinicians may sometimes have little control over client’s daily life stressors or difficulties in accessing care, clinicians clearly should have control over the relevance of treatment for the families who seek their services AND over their relationship building with the client. Engaging clients in the treatment process should not be a passive, but active ongoing process!
Orientation Slides

18. Wraparound Supports Engagement
Addresses family prioritized needs
Plans for needed support
Family-centered and youth guided
Culturally competent
Strengths- and community based
Creative and Individualized
Teams brainstorm how to mobilize professional, natural, and community supports to meet unique needs
Orientation Slides

19. Why Does Wraparound Work?
Theory of Change for Wraparound
Why Does Wraparound Work?
Self
Efficacy
Wraparound strengthens youth and families confidence that they can create positive change in their lives
NEEDS
Efficacy
Natural
Support
System
Integrated Plan
Self-efficacy is the belief in one’s capabilities to organize and execute the courses of action required to produce given attainments. Self-efficacy plays the central role in the cognitive regulation of motivation, because people regular the level and the distribution of effort they will expend in accordance with the effects they are expecting from their actions. People will be more inclined to take on a task if they believe they can succeed. People with high self-efficacy in a task are more likely to expend more effort, and persist longer, than those with low efficacy. Low self-efficacy can lead people to believe tasks are harder than they actually are. This often results in poor task planning, as well as increased stress. Observational evidence shows that people become erratic and unpredictable when engaging in a task in which they have low efficacy. On the other hand, people with high self efficacy often take a wider picture of a task in order to take the best route of action.
Orientation Slides

20. Self-Efficacy
is the belief in one’s capabilities to organize and execute courses of action required to produce given attainments
plays the central role in the cognitive regulation of motivation
People with high self-efficacy are more likely to expend more effort, and persist longer
Low self-efficacy often results in poor task planning, as well as increased stress.
people with high self efficacy often take a wider picture of a task in order to take the best route of action
Orientation Slides

21. Why Does Wraparound Work?
Theory of Change for Wraparound
Why Does Wraparound Work?
Self
Efficacy
Wraparound strengthens the social support system that helps the youth and family succeed
NEEDS
Efficacy
Natural
Support
System
Integrated Plan
The theory of Human Ecology (Bronfenbrenner, 1979), has had widespread influence on the way psychologists and other social scientists approach the study and treatment for human beings and their environments. The theory emphasizes the importance of social influences on human development and functioning. Children are influenced by their parents and the people who play important roles in their lives and in turn these people are influenced by the interrelations of their families, social networks, neighborhoods, communities and cultures. To the extent that parents have networks of family members and friends who share a commitment to the child, for example, parents’ efforts to care for the child are enhanced. One of the central aspects of the theory is that the impact of the parent child relationship on outcomes for the child is directly related to the relationships the parent has had with others. Other relationships for the parent that are supportive and are supportive for the child parent relationship strengthen the impact on the child.
Orientation Slides

22. What or Who are Natural Supports
Natural supports are community resources available for use by youth and families within which are consistent with their cultural beliefs and practices.
Natural supports may involve individuals outside the immediate family and a variety of informal supports found in the neighborhood or larger community.
Natural resources are external to the child and family and, once accessed through active affiliation, become part of the child's and family's strengths.
Orientation Slides

23. Research on Impact of Natural Supports
positively impact chronic disease related health behaviors
increase compliance to routine medical care
improved health for older people with chronic conditions
decrease postnatal depression for new mothers
decrease depression in older women
positive natural supports decrease drug use
positive natural supports decrease HIV risk behaviors
decrease punitive punishment from parents
increase coping, resilience and sustainability for caregivers
Orientation Slides

24. What Natural Supports Do for Caregivers
Natural Supports may support and influence improved and sustained care-giving by
Creating situations to observe and learn about effective parenting from people the family trusts
Providing a sense of attachment and someone to talk to during tough times
Someone to trust and provide respite from many types of demands of care giving
Providing access to resources and material goods
Providing coping resources
Orientation Slides

25. Why Does Wraparound Work?
Theory of Change for Wraparound
Why Does Wraparound Work?
Self
Efficacy
Wraparound creates an integrated and simplified plan for the whole family
NEEDS
Efficacy
Natural
Support
System
Integrated Plan
Families like the Tyler's often have complex and multiple needs that require support from numerous different agencies. Wraparound is a process of bringing all of those providers together with the family and natural supports to decide which of the needs are the most important to be addressed first and develops an integrated and simplified plan for the whole family.
Orientation Slides

26. Seriousness of the Problem
Prevalence of Serious Emotional Disturbance (SED)
Population Proportions (9 to 17 year-olds)
5-9% Youth with SED & extreme functional impairment
9-13% Youth with SED, with substantial functional impairment
20% Youth with any diagnosable disorder
The research and assessment done by Vroon VanDenBerg suggests that the number of children and youth who meet the criteria for severe emotional disorders ranges from 4 to 6% of the general population and the percentage who meet the diagnostic criteria for DSM IV diagnosis is about 15%.
Orientation Slides

27. Children with Behavioral Health Disorders Across Systems
Orientation Slides

28. Fragmented System
Yet, for too many Americans with mental illnesses, the mental health services and supports they need remain fragmented, disconnected and often inadequate, frustrating the opportunity for recovery. Today’s mental health care system is a patchwork relic—the result of disjointed reforms and policies. Instead of ready access to quality care, the system presents barriers that all too often add to the burden of mental illnesses for individuals, their families, and our communities.
Michael F. Hogan, Ph.D Chairman
President’s New Freedom Commission on Mental Health
Orientation Slides

29. Tyler Family Marge, 38 Evan, 39 Billy, 14 Sam, 12 Sally, 12
Major Strengths, Family Culture:
Parents married 17 years
Marge’s parents alive and in the area, care about the family
Marge has entrepreneur skills in area of home cleaning business
Family has history of surviving adversity using their wits
Evan has over a year of sobriety after a decade of untreated alcoholism
Children provide active support to each other
Family culture prioritizes educational goals
Billy knows what “cool” is
I use this set of slides as a way to set context for a training on Systems of Care around the need for integration….
Orientation Slides

30. Major Needs of Tyler Family
From the more detailed description of the Tyler family list concerns or risk factors
Orientation Slides

31. Major Needs of the Tyler Family
Billy:
Serious Juvenile Justice involvement
Breaking and entering, shoplifting, thefts of all types
Two years behind in school but lots of potential
Twins (Sam and Sally):
Bi-polar, extreme mood swings.
In child welfare custody in a specialized foster home
School is having problems controlling behaviors and engaging them in lessons
All school behavior plans have failed, and school is suggesting home bound instruction
Evan:
Verbally and physically abusive to children
unemployed, unable to hold job due to self described “Stubborn attitude about authority”
Recovering from severe alcoholism
Marge:
Family history of major depression (untreated);
Suicidal ideation which is likely to result in death.
Orientation Slides

32. Pairs Activity
After the concerns and risk factors for the Tyler family are discussed brainstorm typical services and plan(s) for them in your county. We are going for typical – what the average youth and family in their situation would get.

33. Typical Plans for Tyler Family
Orientation Slides

34. How complex is the Tyler Family?
Based on initial information, rate this family from one to ten, with one being least complex needs and ten being most complex needs….
What don’t you see that would make this family rate a higher number?
Orientation Slides

35. 26 Helpers and 12 Plans School (5) 2 IEPs (Sally and Sam)
Technical School (2)
Child Welfare (1)
Juvenile Justice (1)
Children’s Mental Health (6)
Adult Mental Health (3)
Employment Services (2)
AA (1)
Housing Department (1)
Bailey Center (2)
Specialized Foster Care (2)
2 IEPs (Sally and Sam)
Tech Center Plan
Permanency Plan
Probation Plan
3 Children’s MH Tx Plans
2 Adult MH Tx Plans
Bailey Center Plan
Employment Services
33 Treatment Goals or Objectives
Orientation Slides

36. Collaborative Efforts in Tyler’s Town
Local Judge is chairing a restorative justice effort to address truancy and violence in schools. Juvenile Justice and law enforcement has major presence in local High Schools.
School Superintendent and United Way are leading an interagency effort for substance abuse prevention.
Local Health Department has a grant and steering committee to decrease teenage Pregnancy.
Child Welfare has a mandated interagency coalition that is planning for multi-agency involved children and youth.
Children’s Mental Health has co-located staff at child welfare supporting family preservation and family group decision making.
Adult Mental Health and Adult Addictions Services are in same agency.
There is a grassroots effort to develop more church involvement in supporting children and families.
Orientation Slides

37. Your Collaboration
Is your communities more, the same, or less collaborative than the Tyler’s town?
Orientation Slides

38. Current Services to Tyler Family
School has IEP for each of the twins and extensive behavior support and planning.
Billy is in a tech center but is rarely in school, school has offered many adaptive plans but none have worked.
Both schools call parents frequently.
Child welfare has substantiated Dad’s abuse of twins, has removed them from the home, created a strict reunification plan that includes family therapy and supervised visits
Twins are in specialized foster care with care and a therapist who supports the foster parents.
Twins are in therapy, two different therapists and a psychiatrist
TSS to help out with Billie
Juvenile Justice has just released Billy from detention over breaking and entering, Billy has new charges of theft,
Court ordered therapy
Restitution supervised by local youth services agency with a counselor and mentor
Housing is trying to find safer housing
Marge sees a psychologist occasionally in crisis times and has been referred to a psychiatrist, went once but does not want to go back.
Evan goes to four AA meetings a week and sees his sponsor twice a week, calls daily
Evan goes to court ordered anger management
Evan is working with Vocational Services on employment skills
Orientation Slides

39. Monthly Appointments for the Tylers
Child Welfare Worker
Marge’s Psychologist
Marge’s Psychiatrist ?
Billy’s therapist
Billy’s restitution services
Appointments with Probation and School 2
Family Based
Therapeutic Support Staff 12
Evan’s anger management
Children’s Psychiatrist
Other misc. meetings:, Housing, Medical 5
AA Meetings
Also, consider daily schedule (School, tech center, and vocational training) and the dozen or more calls from the schools each month.
Orientation Slides

40. Comments from the Files:
Parents don’t respond to school’s calls
Family is dysfunctional
Parents are resistant to treatment
Home is chaotic
Billy does not respect authority
Twins are at risk due to parental attitude
Mother is non-compliant with her psychiatrist, does not take her meds
Father is unemployable due to attitude
Numerous missed therapy sessions
Attendance at family therapy not consistent, recommend group therapy for parents
Orientation Slides

41. Mutual Perspective
How do the professionals involved with the Tyler family view this family, and their role in the family? Do they see their role as “Rescuer” “Stabilizer” “Enforcer” “Supervisor” “Teacher”?
How does the family view the professionals? Does the family feel that they are asking for help? Does the family want the same help as the help the professionals want to give?
Orientation Slides

42. Help isn’t help unless it is asked for!*
Sometimes people need help even though they don’t ask for it. How can we engage them in a way that helps them trust us when we see a need that they do not see? Will any plan work if the Tylers are not on board or don’t see the plan is theirs?
*Quote from Help: The Original Human Dilemma
(pub. By Harper, 2004), author is Garret Keizer
Orientation Slides

43. Cost Specialized Foster Care Psychiatrist Psychologist
Therapy (Individual and Family Based)
Therapeutic SS
Tech Center
Vocational Training
School
Restitution
Per Month
Plus the cost of the salaries for the public staff and the time from AA. If there is a crisis, detention, or higher levels of care the cost goes up considerably
Orientation Slides

44. Going From Collaboration to Integration is a Needed Shift
Collaboration: Agencies are familiar with each other’s missions and roles, key staff work with each other at the child/family level, but retain single system decision making power and planning.
Integration: Agencies are familiar with each other’s missions and roles, key staff work with each other at the child/family level, sharing decision making in a team format that includes the family, producing a single plan that meets all system mandates and that is owned by the entire team.
Orientation Slides

45. Rate your town…
On collaboration, rate your town from one to ten, with ten being most collaborative?
On integration, rate your town from one to ten, with ten being most integrated?
If ratings were different, what are non-blaming or shaming reasons for the differential ratings? For example, staff may not be trained to integrate.
Orientation Slides

46. First: Crisis Stabilization
Before team building, stabilize immediate crises with safety plan for Billy’s criminal behavior, Marge’s suicidal behavior and maintenance of Evan’s sobriety
Crisis planning involves prediction of worst case scenario, functional assessment to target plan on function of crisis behaviors, implement individualized, strengths-based, culturally competent prevention efforts, and plan for what to do if crisis occurs
Orientation Slides

47. Initial Tyler Wraparound Team
All of the immediate family (5)
Marge’s Parents (2)
Twin’s behavioral staff from school
Probation Officer
Child Welfare Case Worker
Marge’s business co-owner
Evan’s AA Sponsor
Care Coordinator
Family Support Partner
14 total, team can change over time…
Later, teachers, therapists, vocational staff, others in consulting roles
Orientation Slides

48. Support Marge’s business efforts to keep income rolling in
Next, Prioritize Needs and Plan Notice that needs are addressed in sequence with integrated approach to selection of need priority, with family in control of final decisions with court approval
Billy’s thefts – highly individualized plan using the “cool” grandfather to help stop criminal behavior, do individualized restitution to victims, and build on Billy’s strengths
Support of twins and highly individualized plan to gradually move toward reunification, done at approximately same time as #3 so that school, foster home, and home are consistent
Plan to stabilize twin’s school behavior using Marge, grandparents and others as volunteer aides, including accelerated plan to get Billy up to grade level using volunteer aides who are “cool”
Support Marge’s business efforts to keep income rolling in
Continued Vocational Services for Evan, with team support of job finding
And so on, over a year (predicted)
Orientation Slides

49. Benefits of an Integrated Approach for the Tyler Family and the Town
Tyler family has real hope from their plan and process, have more energy each time a goal is met.
The professionals involved get to maximize the use of their own expertise. For example, which plan would you rather be the psychiatrist in? Or the teacher?
The professionals get to practice integration skills which will benefit 1000’s of other families, trading control and autonomy for outcomes at the family level, and more satisfying jobs. Also may decrease professional turnover.
Taxpayers get return for their investment
Potential multi-generational positive effect
Community building a family at a time.
Orientation Slides

50. Cost
Not why we are here, but the real five year cost of Tylers was in excess of $250,000 – real money paid by real taxpayers
Is the “typical plan” a good deal for taxpayers?
Orientation Slides

51. Permanency
Permanency is one of the primary goals for youth in the child welfare system. Historically youth who meet the criteria for eligibility in this study (e.g. in child welfare custody and with a long history of using extensive amounts of behavioral health services) do not consistently achieve permanency in community homes. Many bounce from placement to placement until they are 18. In this study many of these youth had primary permanency goals do not focus on reunification and people to provide adoption or guardianship placements had not been identified. And If these children and youth are placed with a family who plans to adopt, it can take 6 to 18 months to finalize. In this project permanency was defined as moving back home or into a home that plans to do guardianship or adoption. The chart shows average days per child per 180 day period. The first two periods were prior to assigning them to the study. The next three were for the 6, 12, and 18 month periods following assignment.
The chart on the left shows the average number of days in a permanent placement for the three groups per 180 day period. The chart on the right shows the percentage of youth who were in a permanent placement for some part of the 180 day evaluation periods.
Results
Both wraparound groups achieved significantly higher rates of permanency than did the control group and the DHS wrap group achieved significantly higher levels of permanency than did the NC wrap group.
Orientation Slides

52. THE Placement
The most important part of finding the placement is really getting to know the strengths, culture and needs of the youth.
Talk to the youth at length and also talk to people who know the youth (caregivers, former caregivers, teachers, etc)
Strengths include people who might provide some level of support
Needs focus on what it will take in an environment to be successful for the youth and what the youth wants out of life
Needs include the challenges that make the youth hard to place
Once you know the youth use the information to match to THE placement
Use the strengths to sell the youth to the placement
Be very honest about the challenges and needs so placement knows what to expect
Plan with the youth and placement before the youth arrives so the initial experience is better
Frequent communication and support over time to youth and placement once there
In the meantime
Stall
Use the same principles and keep working on the THE placement if a temporary stop is required
The interviews with the three caseworkers who became facilitators revealed that one of the primary reasons for success was a change from finding a placement for the youth to finding the placement that would work for the youth. This was especially important for many of the youth in this study because the severity of challenges severely limited what would work. The staff explained why wraparound helped them succeed at finding the placement. The most important part of the process was completing the strengths, needs and culture discovery and really getting to know the youth. Through this process the facilitator was able to identify the youth’s needs which would define the special characteristics of the placement. The strengths were then used to “sell” the youth to potential caregivers, and to build a long term support system for the youth. This often included siblings and extended family who would not be caregivers but who wanted to be involved in the youth’s life. Once caregivers were identified and engaged, extensive work was done to help them prepare to be successful. Then once the placement was completed, the facilitator provided frequent support to work through problems that came up.
The facilitators were asked how they provided for the youth until the placement was found. They reported that they were able to retain youth in current placements longer through more frequent contact with caregivers and when they were forced to find a less than optimal placement they continued to seek the placement even though they had just placed the youth.
Orientation Slides

53. Youth Story - THE Placement
Youth was 16 and in lock down for shoplifting and AWOL from TFC. History of sexual abuse and had become sexually reactive. Multiple failed placements because of sexual and aggressive to other kids. No supports or visits for several years.
Strengths – good with adults, motivated to succeed
Challenges – around younger kids or kids in home, learning disability requires very structured situation and instructions
THE placement – a mature couple with no other children in the home
The Results – found grandmother and brother who want to support him but could not provide placement. Developed long range vision of work with need for supported living. Completed school and went to Job Corp. Will return to live with grandparents supported by brother until he is ready to go out on his own.
One example of finding the placement involved a 16 year old youth who had been in the system for more than five years. When the facilitator started working with him he was in detention for shoplifting while AWOL from a TFC placement. He had multiple failed placements and now had an alternative permanent placement plan. The facilitator learned through the strengths, needs and culture assessment that he did well when around people older than himself and that he was motivated to be successful. She also discovered he felt alone in the world with no family contact. She found he had an older brother and grandmother who cared about him but could not be caregivers. She helped him establish relationships with them and found a mature couple with no other children currently in their home. He was successful in the placement and attended Job Corps to prepare for independent living. He will return to live with grandmother and work in the community.
Orientation Slides

54. Stability of School Placement
The second measure of stability is for school placements. The data was gathered from the caregiver interview within the evaluation study and only included data on youth who have completed caregiver interviews. The residential stability and permanency data was from KIDS and included all but one of the youth in the study (restricted file).
The charts in this figure show the number in schools per six month period for the three groups. The chart on the left shows that data for youth with two completed interviews which included 21 control, 13 DHS wrap and 16 North Care wraparound subjects (baseline and six months). The gray columns show the average number of schools (one would be stable) per child in the six months prior to enrollment and the black the next six months. The chart on the right shows the data for stability for the second six month period after enrollment for the nine control, 7 DHS wrap and 8 North Care wrap who had completed three interviews (through twelve months).
Results
At both time intervals the control youth were having less school stability than during baseline and indications are that this was getting worse over time (comparing the chart on the left to the chart on the right). The two wraparound groups had improved school stability at each time interval and the differences were significant. The North Care group did better on this measure than the DHS group although the differences were not significant.
Orientation Slides

55. Summary of Results Outcome (Data Source) Positive Direction Comp
DHS Wrap
NC Wrap
Average Number of Days in Permanency Setting (KIDS) 7
92*
63*
Percent of Youth in Permanent Placement 12 to 18 months (KIDS)
4.1%
55.7%**
29.5%*
Change in Number of Residential Moves per Six Months (KIDS)
+ 0.7
- 0.6*
Number of Schools in Six Month Period (Caregiver Survey)
2.0
1.2*
1.4
Changes in Restrictiveness of Living Scale (KIDS)
-1.26**
-.32*
Change Level of Family and Caregiver Stress (Caregiver Survey)
+ 4.4
- 6.0**
+ 3.6
Change in Level of Youth Problems (Ohio Scales)
+ 1.3
- 5.8**
+1.8
Change in Level of Youth Functioning (Ohio Scales)
- 5.2
+ 3.0**
- 1.1
Change in Level of Impairment (CAFAS)
- 11.4
- 25.0**
-10.5
Reduction in Medicaid Spending (OHCA)
$75,383
$400,906**
$222,384*
The above table summarizes the preliminary results of the study. This data was collected through the 15th of January Data collection should be completed by September The results of this preliminary analysis is presented in more detail on the following pages. The first column of the table shows the targeted outcome measure and in parenthesis shows the data source. The second column shows the expected change in the outcome (e.g. it is expected that the number of days in permanency would increase while the amount of caregiver and family stress would decrease). The third column shows the results for the comparison group, the fourth column for the DHS wraparound group, and the last column shows the NC wraparound group.
An * represents a result that is significantly better than the comparison group (at least p>.05). An ** represents a result that is significantly better than both the comparison and North Care wraparound groups.
Orientation Slides

56. Impact on Medicaid Spending
One of the primary goals of the project was to move youth to less restrictive levels of care and as a side benefit to reduce overall behavioral health spending by reducing the amount of spending for more restrictive levels of service. The chart above shows the amount of spending change between the year prior to the study and the first eighteen months after assignment. This data is from the OHCA billing database. The first set of columns shows the amount of change for the first 180 days for each of the three groups (this is total dollars per 180 day period). All three groups spent more money than during baseline. The next two sets of columns show the amount of change during the second and third 180 day periods. The final set of columns shows the total effect over the first 480 days after assignment.
Results
The amount spent on both of the wraparound groups was significantly less than the amount spend on the control group over the 480 days. The amount spent on the DHS group was significantly less than the amount spent on the North Care group during that time.
Orientation Slides

57. Facilitator Credentialing using VVDB tools…
Novice -- has completed 24 hours of class room (or E-Learning) instruction, in-class behavioral rehearsals, pre and post tests, and 20 hours of shadowing
Practitioner -- has a professional development plan, is receiving appropriate supervision and coaching, and has demonstrated competency using VVDB documentation and observation review tools.
Orientation Slides

58. VVDB Observation and Review Tools
Either the Supervisor/Coach or Coach actively reviews document products and observes key activities based on NWI Phases and Activities
Documentation Reviews: SNCD; Wrap Plan; Functional Assessment; Crisis Plan; Progress Notes; Transition Plan
Observation Reviews (live): Initial Engagement meeting; Initial Team Meeting; Follow-up Meeting
Orientation Slides

59. Barriers to High Fidelity Wraparound in PA
In small groups, assign a recorder with good hand writing (the notes will be turned in)
Begin the discussion by introductions. Then, list out top barriers which may get in the way of implementing wraparound as defined by the National Wraparound Initiative (30 minutes)
Prioritize the list and choose the top barrier (5 minutes)
Then (most important) make a recommendation for removing the top barrier. (10 minutes)
Orientation Slides

60. Remember one thing…
High Fidelity Wraparound is a process of integration for children and families with co-occurring disorders. It is specifically designed to lead to positive clinical outcomes and is based on a theory of change
In general, the field has greatly underestimated the complexity of doing a good job with wraparound at the supervisor and staff levels.
Orientation Slides