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Next Steps Towards a Trauma-Informed System of Care Presented By: Douglas E. Patrick, JD, LCSW Manager, Children's Behavioral Health System Children's.

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Presentation on theme: "Next Steps Towards a Trauma-Informed System of Care Presented By: Douglas E. Patrick, JD, LCSW Manager, Children's Behavioral Health System Children's."— Presentation transcript:

1 Next Steps Towards a Trauma-Informed System of Care Presented By: Douglas E. Patrick, JD, LCSW Manager, Children's Behavioral Health System Children's Behavioral Health Services Department of Health and Human Services Arabella Perez, LCSW Director THRIVE Initiative Sarah Krichels Goan, MPP Evaluator Hornby Zeller Associates, Inc. Jennifer McLaughlin Youth Youth M.O.V.E. Michelle LaPointe Family Member G.E.A.R. Parent Network

2 working together for a brighter tomorrow Goals Provide an introductory overview of trauma theory and system of care principles Introduce trauma informed principles and domains Provide an overview of the TIAA © purpose, development and implementation Provide clarity around state expectations for continuous quality improvement planning

3 working together for a brighter tomorrow What Research Tells Us Estimated 3 million children and adolescents in the United States are exposed to serious traumatic events each year. Nearly one out of three adolescents have been physically or sexually assaulted by the age of sixteen. (Boney-McCoy & Finkelhor, 1995) Violent crime victimization among youth found to be twice as high as the rate for adults. (Hashima & Finkelhor, 1999) High-rates (between 50% and 70%) of Post-Traumatic Stress Disorder in child/adolescent and adult public service users. (Macy, 2002, Kessler, 2000, Switzer, et al., 1999) PTSD rates among Medicaid enrollees found to be highest among children 5-12 years (609.5 per 1000). (Macy, 2002) Child/Adolescent trauma survivors found to have higher rates of mental health service use and to use more acute mental health treatment services, including: inpatient hospitalization, crisis services, and residential treatment services at higher cost. (Frothingham, et al. 2000; Macy, 2002, Newmann, et al., 1998; NTAC, 2003)

4 working together for a brighter tomorrow Implications for the System  When service systems do not appropriately assess, identify, and effectively address the underlying trauma-related needs of these children and families, the result is often that services are: more expensive ineffective and overwhelming to the child and family re-traumatizing for the child Resulting in poorer treatment outcomes  Given the pervasiveness of traumatic experiences among children/youth receiving public mental health services and the potential long-term costs to individuals, service systems, and society, these findings underscore the importance of trauma screening and identification early in the treatment process and the need for establishing and testing more trauma-informed approaches to service delivery and treatment.

5 working together for a brighter tomorrow A Systemic Approach Due to pervasive nature of trauma, systems of care need to take systemic approach to trauma A Trauma-informed system includes:  Universal trauma screening, assessments and service planning – integrating all components;  Focus on recovery, resiliency, strengths-based, and skill building;  General awareness and understandings of all stakeholders of trauma, its effects and potential triggers;  Changes in policy and practice to support a trauma sensitive approach throughout the system and participating agencies to reduce incidences of re-traumatization; and  Crisis Management from a trauma informed perspective.

6 working together for a brighter tomorrow Why Develop a Trauma Informed System of Care Approach in Maine Data collected and analyzed by Dr. Jay Yoe, Ph.D. of DHHS showed clearly that compared to others, children and youth trauma survivors in Maine:  Were at greater risk of significant harm;  Were likely to experience co-occurring challenges physically, developmentally and with substances;  Had significantly greater challenges in the areas of child/youth and parent/caregiver acceptance and engagement with service providers;  Were more likely to use mental health services and high-end services for greater periods of time; and  Had 73% higher mental health service expenditures and 51% higher overall treatment expenditures.

7 working together for a brighter tomorrow State perspective Six years ago Maine was awarded a six year grant by the Federal Substance Abuse and Mental Health Services Administration to develop and implement a System of Care for Children that would be:  Trauma-Informed  Family Driven  Youth Guided  Culturally and Linguistically Competent

8 working together for a brighter tomorrow Youth & Family Perspective

9 working together for a brighter tomorrow Overview of System of Care and Trauma Theory Understanding System of Care principles and Trauma-Informed Approach

10 working together for a brighter tomorrow Comprehensive Community Mental Health Services for Children and Their Families Program Legislatively initiated in 1992 Goal: Develop community-based systems of care for children with serious emotional disturbance and their families Charged to implement the goals and recommendations of the New Freedom Commission and transform children’s mental health services.

11 working together for a brighter tomorrow Systems of Care A system of care is a coordinated network of community-based services and supports that are organized to meet the challenges of children and youth with serious mental health needs and their families. Families and youth work in partnership with public and private organizations so services and supports are effective, build on the strengths of individuals, and address each person’s cultural and linguistic needs. A system of care helps children, youth and families function better at home, in school, in the community and throughout life. Gary Blau, Child, Adolescent and Family Branch, CMHS, SAMHSA

12 working together for a brighter tomorrow System of Care Values Family Driven Youth Guided Cultural and Linguistic Competence Trauma-Informed

13 working together for a brighter tomorrow Definition of Family Driven Care Family-driven means families have a primary decision making role in the care of their own children as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation. This includes:  choosing supports, services, and providers;  setting goals;  designing and implementing programs;  monitoring outcomes;  managing the funding for services, treatments and supports and;  determining the effectiveness of all efforts to promote the mental health and well being of children and youth. Osher, Federation of Families for Children’s Mental Health and Child, Adolescent and Family Branch, CMHS, SAMHSA

14 working together for a brighter tomorrow Definition of Youth Guided It is when young people have the opportunities to achieve positive development, assist in their successful transition to adulthood, and develop a deeper connection to their community and peers It occurs when:  The voice and actions of youth are valued  Youth are engaged from start to finish  Youth are utilized as a resource in the development of themselves and their communities  Youth are provided with an environment where they feel safe to voice opinions and won’t be judge based on experience nor age

15 working together for a brighter tomorrow Cultural Competence behaviors attitudes policies structures practices Requires that organizations have a clearly defined, congruent set of values and principles, and demonstrate behaviors, attitudes, policies, structures, and practices that enable them to work effectively cross-culturally. (adapted from Cross, Bazron, Dennis and Isaacs, 1989) Slide Source© 2010 National Center for Cultural Competence

16 working together for a brighter tomorrow Slide Source: National Center for Cultural Competence, 2010 Title VI, Section 601, Civil Rights Act of 1964 Non- Discrimination based on Race, Color, National Origin, Age, Disability, Sex U.S. Department of Justice U.S. Department of Education U.S. Department of Health & Human Services Linguistic Competence: Legal Mandates, Regulations, Guidance, and Standards

17 working together for a brighter tomorrow Maine Human Rights Act §4552. Policy To protect the public health, safety and welfare, it is declared to be the policy of this State to keep continually in review all practices infringing on the basic human right to a life with dignity, and the causes of these practices, so that corrective measures may, where possible, be promptly recommended and implemented, and to prevent discrimination in employment, housing or access to public accommodations on account of race, color, sex, sexual orientation, physical or mental disability, religion, ancestry or national origin; ……. [ 2005, c. 10, §1 (AMD).]

18 working together for a brighter tomorrow What is Trauma and Why Does it Matter? The personal experience of interpersonal violence including sexual abuse, physical abuse, severe neglect, loss, and/or the witnessing of violence, terrorism and/or disasters. (NASMHPD, 2004) Historical Trauma, Stigma Trauma and Intergenerational Trauma We care clinically but what about as a system? Evidence – Adverse Childhood Experiences and local research Preventable health and human event with enormous societal cost

19 working together for a brighter tomorrow What is Trauma-Informed Means understanding the role that violence and victimization play in the lives of large numbers of children and families Providing services and supports in a manner that is welcoming, respectful and appropriate to trauma survivors A trauma informed organization makes every effort to avoid re-traumatizing individuals

20 working together for a brighter tomorrow Trauma-Informed Theory Instead of asking “what is wrong with you?” a trauma-informed approach asks “what has happened to you?” Roger Fallot and Maxine Harris, Using Trauma Theory to Design Service Systems Universal precautionary approach…..

21 working together for a brighter tomorrow Trauma Informed Principles/Philosophy 1.Safety 2.Trustworthiness 3.Choice 4.Collaboration 5.Empowerment 6.Language Access and Cultural Competence

22 working together for a brighter tomorrow Safety Because trauma inherently involves a physical or emotional threat to one’s sense of self, families and youth are often especially attuned to signals of possible danger. It is essential then, that service organizations prioritize safety as a guiding principle in order to become more hospitable for trauma survivors and to avoid inadvertently re-traumatizing people who come for services. This holds true for staff as well.

23 working together for a brighter tomorrow Trustworthiness Survivors of trauma report a violation of boundaries resulting in a justified inability to trust others; especially those in power and authority. A trustworthy organization is one that demonstrates appropriate boundaries, task clarity, clear and consistent policies and reasonable expectations for providers, families, and youth. The trauma-informed organization recognizes how trust has been violated and seeks to earn trust.

24 working together for a brighter tomorrow Choice Maximizing family and youth choice and mutuality. Allows family and youth to choose where, how and when they will receive services. They also have an active voice in selecting a provider and determining treatment.

25 working together for a brighter tomorrow Collaboration Policies, practices and relationships that encourage empowerment, partnership, and participation, as well as strength based and community-based approaches. Having the ability to share power and value both perspectives:  Collaboration with family and youth allows for very specific insight. Only they know their responses, their needs and history better then anyone else does.

26 working together for a brighter tomorrow Empowerment It is the state of feeling self-empowered to take control of one's own destiny. To become aware that one’s experience can enhance service systems and promote change. Program opportunities to develop skills and enhance knowledge of the consumer.

27 working together for a brighter tomorrow Language Access & Cultural Competence Extent to which policies, procedures, staff, services and treatment are sensitive to family and youth:  cultures  traditions  beliefs The agency’s policies and procedures acknowledge that behaviors and responses to trauma are influenced by culture. Ensure language access through:  policy  training  reimbursement

28 working together for a brighter tomorrow Achieving System of Care Goals There is a need for common understanding about basic principles and this webinar is a step toward achieving the goal Providers are critical in implementing these principles An assessment of providers was needed to determine strengths and needs –this was the Trauma Informed Agency Assessment that was to be taken by all agency staff and a percentage of family and youth served by the agency. Data specific to agencies could be used to assist agencies in making change according to the unique strengths and needs of each agency Agencies will implement Continuous Quality Improvement activities with the support of Children’s Behavioral Health Services, Thrive and other organizations

29 working together for a brighter tomorrow Overview of the Trauma- Informed Agency Assessment: Development, Implementation, Scoring and Validation

30 working together for a brighter tomorrow Goals of the TIAA Tool Provide agencies a mechanism to identify areas where they are successfully trauma- informed, and pinpoint areas where they want to improve. Guide the CQI process for making the system even more trauma-informed.  Support data-driven decision-making! Help agencies gauge whether CQI efforts were successful.

31 working together for a brighter tomorrow Development Phases Planning: created conceptual framework, method for data collection, involved key stakeholders Pilot Testing: implemented pilot tests, made revisions based on results Implementing: statewide assessment and response monitoring

32 working together for a brighter tomorrow The Domains Children, Youth and Families Physical and Emotional Safety Youth and Family Empowerment Trustworthiness Commitment to Trauma- informed Philosophy Cultural Competence Trauma Competence

33 working together for a brighter tomorrow How is it Scored? Standards for each core trauma domain have been established.  Questions correspond to a domain.  Each question uses 5-point scale. Total potential score = number of questions that comprise the domain multiplied by 5 Total actual score = summation of given responses Final score = (total potential score/total actual score)*100

34 working together for a brighter tomorrow Tool Validation Cronbach’s Alpha  Tests on the domains fall within acceptable ranges Exploratory Factor Analysis  Groupings make sense  Each question contributes meaningfully to domain results Internal Consistency & Reliability

35 working together for a brighter tomorrow State Expectations For Continuous Quality Improvement : Developing a CQI Plan Re-administering the assessment

36 working together for a brighter tomorrow States Expectations and Continuous Quality Improvement By January 2011, agencies will have completed a CQI Plan required by contracts regarding issues identified in the Trauma Informed Agency Assessment Agencies have been provided with resources including training opportunities, such as this web based training, and a detailed Guide to Trauma-Informed Organizational Development Agencies have been provided with the results from the assessment and many agencies did not obtain the number of responses needed to provide data Additional detailed reports can be accessed by contacting Sarah Krichels Goan at Hornby Zeller Associates.

37 working together for a brighter tomorrow State Expectations Continued Agencies that did not obtain the number of responses needed will re-administer the assessment in Part of their CQI Planning would be to identify how to obtain more responses. There will be a re-administration of the assessment in 2012 for all staff who interact with children/youth for all agencies. Agencies will continue to refine their CQI Plans in the future toward the goals of Maine having the first fully Trauma Informed System of Care!

38 working together for a brighter tomorrow State Expectations Continued Continuous Quality Improvement Plan - System of Care requirements  At least one goal from two separate domains in the assessment  Required Goal: Agencies that did not fully complete the first administration of the assessment must include a goal regarding completion of the next administration of the assessment. This must include objectives and action steps specifically addressing how the agency will ensure that assessment is completed.  Goals may be developed by referring to the “Key Question” section in each domain in the “Guide to Trauma- Informed Organizational Development.”  Objectives, action steps and outcomes may be developed using the “Best Practice Standards” in each Domain.

39 working together for a brighter tomorrow Resources Technical Assistance Partnership for Child and Family Mental Health National Child Traumatic Stress Network The National Center for Trauma-Informed Care National Institute for Trauma and Loss in Children Children’s Mental Health Initiative

40 working together for a brighter tomorrow Resources Child Welfare League of America National Center for Mental Health & Juvenile Justice Traumatic Stress Institute-Klinberg Family Centers Training Center of the Jewish Board of Family and Children’s Services Joyfields Institute

41 working together for a brighter tomorrow Contact Information Douglas E. Patrick, JD, LCSW Arabella Perez, LCSW Sarah Krichels Goan, MPP


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