1. Implementing Effective Intensive Home-Based Treatment Programs
Rick Shepler, Ph.D., PCC-S
Patrick Kanary, Director
Center for Innovative Practices
Begun Center for Violence Prevention
Case Western Reserve University

2. Workshop Focus Areas
Intensive Home-based Treatment: best practice for youth with multiple and complex needs and their families.
IHBT model components
Implementation considerations including staffing, team composition, policies, risk management, and funding
Central program role for IHBT supervisor: active supervisory clinical oversight
IHBT fidelity and outcome measures
IHBT training focus areas

3. It takes a community …. Shared burden- shared risk
No single system can manage the multiple issues of at-risk youth and their families alone
Mutual responsibilities: we all play a role
Youth and family
Providers
Child-Serving Systems
Community (supports)

4. Critical Service in a Comprehensive System of Care
IHBT expands the continuum of care to increase the availability of the less restrictive service options for youth at-risk of out-of-home placement due to behavioral health issues.
Pivotal: most intensive community-based option prior to more restrictive placement options

5. Intensive Home-Based Treatment Services
IHBT is an intensive, time-limited mental health service for youth with serious emotional disabilities and their families, provided in the home, school and community where the youth lives, with the goal of stabilizing mental health concerns, and safely maintaining the youth in the least restrictive, most normative environment.
Comprehensive set of mental health services integrated into a seamless set of services delivered to the family.
Main Purposes:
Placement prevention
Reunification
Stabilization and safety
Definition of IIHS

6. Effective Alternative to Custody Relinquishment
Youth can remain in their homes and receive the necessary behavioral health services needed for community stability.
Reduced out of home placements
86% in recent 15 site IHBT evaluation (total youth served)

7. Do What Works
Evidence shows that offering a full range of community-based alternatives is more effective than hospitalization and emergency room treatment
The Commission’s final report endorses the expansion of home and community-based services and the move toward the use of evidence-based practices
President’s New Freedom Commission on Mental Health
Transition to importance of evidenced-based practice and utilization of outcomes

8. Percentage of children still at home post-Intensive Family Preservation Services
State
Months Post IFPS
% In Home
Kansas 12
91%
Wayne Co., Michigan 6 88
Kentucky 87
Marion Co., Indiana 83
North Carolina 82
Missouri 79
Washington 77
Mean
84%

9. Michigan Families First Effectiveness Study (Blythe and Jayanarte 2002)
Randomly assigned high-risk families to either family preservation services (home-based) or traditional child welfare services including foster care.
At 6 months after IFPS, 88% of children were living at home compared to only 17% in the non-IFPS group.
At 12 months, 93% of IFPS children were at home compared to 43% of non-IFPS children.
Family preservation evidence

10. IHBT Grant Study 2009 (394 Youth Served)
Placements Avoided
86% of youth served, all at-risk of out of home placement, were maintained at home and in the community at discharge
100% of youth ages 4 to 6 remained in their homes safely
School Success
Passing grades increased from 65 to 77%;
Disciplinary problems decreased from 68 to 49%;
Juvenile Justice Outcomes
50% drop in youth arrested (44% to 21%);youth on probation (27.5 to 13%);youth detained (13.5% to 7.1%)
12/24/2018

11. Aggregate Ohio Scales Scores At Admission and Discharge—Parent Ratings
During IHBT, parents rated youth as having fewer problems and better functioning. They were also more hopeful and more satisfied at the conclusion of treatment than at admission. Mean values are shown above the bars, and p values (significance levels) of differences between admission and discharge using paired samples t tests are shown below the graph. Not only are the differences statistically significant; they also show meaningful clinical change.
Based on
309 cases
p<.0001
p<.0001
p<.0001
p<.0001

12. Aggregate Ohio Scales Scores At Admission and Discharge—Worker Ratings
The worker ratings are concordant with the parent ratings, showing significant (and clinically meaningful) improvement in functioning and decrease in problems.
Based on
296 cases
p<.0001
p<.0001

13. Demonstrate Program Effectiveness MST Dashboard FY 09, FY 10, FY 11
Indicator
Value (Target)
Total Cases Discharged
1598
Percent of youth at home
87.84% (90%)
Percent of youth in school
86.89% (90%)
Percent of youth with no new arrests
77.79% (90%)
Percent of youth completing treatment
85.39% (85%)
Average Adherence Score
0.703 (0.61)
12/24/2018

14. IHBT Benefits
IHBT offers direct service supports to other child-serving systems (education, juvenile justice, child welfare) and assists them in safely maintaining youth safely in less restrictive settings.
Increases positive outcomes for their system (school success; decreased arrest rates, decreased abuse and neglect, etc.)
Saves their system money
IHBT actively assesses and manages youth and family risk
Mental health stabilization
Family Stability
Reduced involvement in Juvenile Justice System
Increased school success
Positive outcome and cost benefit to the family and other child-serving systems

15. Weighing the Costs
“The question is not whether we can afford to invest in every child; it is whether we can afford not to.”
Mariann Wright Edelman
“It is easier to build strong children than to repair broken men.” Frederick Douglas

16. New Evidence on the Monetary Value of Saving a High Risk Youth (Cohen & Piquero, 2008)
Estimate the present value of saving a 14-year-old high risk juvenile from a life of crime to range from $2.6 to $5.3 million (p. 25)

17. IHBT as Alternative to Out of Home Placements
Foster Care
Therapeutic Foster Care
Group Home
Psychiatric Hospitalization
Residential Treatment Facilities (Unlocked to locked)
Incarceration

18. What Cost Analysis Shows
“Intensive Family Preservation Programs that adhere closely to the Homebuilders model significantly reduce out-of-home placements and subsequent abuse and neglect. We estimate that such programs produce $2.54 of benefits for every dollar of cost.”
Washington State Institute for Public Policy (WSIPP): (Miller, 2006) 

19. Fiscal Impact for System Stakeholders (2008 Data)
Placement Type
Average Cost Per Diem
Annualized Cost
System(s) Impacted
Foster Care Level IV
$123.90
$45,224
Local Job and Family Services
Group Home
$125
$45, 625
Local Job and Family Services; Juvenile Courts
Residential Treatment (non- secure)
$200.56
$73,204
Local Job and Family Services; Juvenile Courts; School Systems
Residential Treatment (secure)
$335
$122,275
Juvenile Commitment
$440
$145,200
ODYS; Local Juvenile Courts
IHBT (average cost per treatment episode)
$7,500
All
12/24/2018

20. Cost Benefit Estimate from IHBT Grant
Over $16.4 million in placement costs saved at the cost of approximately $3 million (IHBT for 394 youth)
Total Cost Benefit over $13.4 million saved for 394 youth served (IHBT grant 2009)
The total cost savings per youth is $34,154
For every dollar spent in IHBT/MST there was a return of $5.55 or 555% in placement costs avoided.
12/24/2018

21. Key Home-based Service Models
Homebuilders (1974): Original home-based model; often referred to as family preservation; target population is youth at-risk for abuse and neglect (length of stay- 4 to 6 weeks)
Kaleidoscope (1973) Karl Dennis; wraparound model developed (no eject no reject policy)
Philadelphia Child Guidance Model: Structural Family Therapy home-based therapy model
Multisystemic Therapy (MST): EBP for juvenile justice 3- 5 months
IHBT: Ohio’s intensive home-based treatment model: for youth with SED who are at-risk of placement; returning from placement; or have a significant safety/risk issue that potentially puts them at risk of placement
Integrated co-occurring treatment (ICT): for youth with co-occurring substance use and mental health disorders (3 to 6 months)
Key home-based models.

22. IHBT: Service Access
Service delivered where the youth lives and functions: home, school, and community at times that are convenient to the family
Access to information
Family dynamics and interactional patterns
Recovery environments
Access to people
Family
School
Court
Community
Natural supports
Access for interventions: implemented where behaviors occur

23. Intensive Home-Based Service Delivery Model
Location of Service
Home and Community
Intensity
Frequency: 2 to 5 sessions per week
Duration: 4 to 8 hours per week
Crisis response & availability; active safety planning and monitoring
24/7
Active safety planning & monitoring
Ongoing
Small caseloads
4 to 6 families per FTE; 8 to 12 for team of two
Flexible scheduling
Convenient to family
Treatment duration
3 to 6 months
Systemic engagement and community teaming
Child and family teaming; skillful advocacy;
family partnering; culturally mindful engagement
Active clinical supervision & oversight
24/7 availability; field support; individual & group
Program structure and credentials
Licensed BSW and above; MA preferred
Program size: 4 to 8; .5 to 1 FTE IHBT Supervisor
Individual provider versus teaming approach
Comprehensive service array
Crisis stabilization, safety planning, skill building, trauma-focused, family-focused; resiliency & support-building interventions; cognitive interventions

24. Differences Between IHBT & Traditional Services
Services delivered in the home and community
24/7 availability & response by IHBT team
Frequency & duration matches need
Flexible Scheduling
Lead role in service coordination
Small Caseloads <8
Time-limited
Comprehensive mix of services
Outpatient
Clinic-based
No 24/7 availability by team
One hour weekly appointments
Appointments during office hours
Limited opportunities for collaboration
Large Caseloads >30
Services are ongoing
Therapy only

25. Differences Between IHBT & Family Preservation
Target population: youth with serious emotional disabilities
Goal: Stabilize youth mental health concerns; reduce out of home placements; increase functioning
Intensity: 4 to 6 hours per week
Small Caseloads <8
LOS: 3 to 6 months
Credentials: BSW and above; MA preferred
Comprehensive mix of services: trauma-focused; family-focused; skill building; crisis stabilization; resiliency & support building interventions
Family Preservation
Target population: families at-risk of abuse and neglect
Goal: Reduce abuse and neglect; increase family stability
Intensity: hours a week per family
Caseload: 2 to 4
LOS: 1 to 3 months
Credentials: BSW and above; BSW most common
Skill building focus; parenting focus; crisis stabilization

26. Typical Youth Served
Youth with Serious Emotional Disturbance (SED) with functional impairments
Less intensive services were unsuccessful
Multiple system involvement
At-risk of placement due to safety issues
Multiple risk factors; Few protective factors
Skill set deficits
Youth need additional supports, active facilitation, and accommodations for success

27. Parents and Families
System has not engaged youth and family effectively
Families who have difficulty with service access (work, transportation, poverty)
High stress – Low resource
High family conflict
Current parenting skill set unsuccessful in dealing with youth's mental health needs
Parents need significant levels of support (few external supports)
Trust issues with the “system”

28. IHBT Eligibility Criteria
Youth with serious emotional disorders
At risk for out-of-home placement; or
Returning from out of home placement; or
has significant behavioral health concerns that require active and intensive safety planning, crisis stabilization, and monitoring
Youth Is under the age of 18; or
Youth age 18 through 21 who are still living at home and attending high school or under the jurisdiction of another child serving system

29. IHBT Service Progression and Processes
Engagement and Assessment (High Intensity)
Engagement (youth, family, & collaborative partners)
Crisis Stabilization and Safety Planning
Assessment
Treatment (High to Medium Intensity)
Evidenced-based individual and family treatments and supports
Skill Building, Skill Consolidation, and Generalization
Enhancement of Positive Support Network
Preparation of Continuing Care and Support Needs (Decreasing Intensity)
Solidify continuing care and support needs
Linkages, Closure, & Follow-up
Increased reliance on informal supports
3 main phases of work: 1st phase (2 to 4 weeks) is focused on positive engagement; stabilization of presenting crises and safety needs; and thorough assessment; establish collaborative relationships with other system providers
2nd phase: (middle 6 to 8 weeks) Treatment: individual and family therapy; skill building & generalization
3rd phase (2 to 4 weeks) Enhancement of Positive Support Network: Build supports comprised mainly of informal supports (family, faith, and friends). Ritual closing celebrating successes.

30. Single Point of Clinical Responsibility
IHBT providers take a lead role in facilitating the coordination of formal and informal services and supports, as guided by the youth and family.

31. System of Care Service Philosophy
IHBT Model Components
Resiliency-Oriented Perspective
Home-Based Service Delivery
System of Care Service Philosophy
Multidimensional Assessment
Comprehensive Treatment Array Matched to Needs and Strengths

32. System of Care Principles and Values
Least restrictive environment
Treatment responsiveness and persistence
Advocacy and protection of rights
Integrated, coordinated, and comprehensive services
Culturally and linguistically competent services
Strength-based perspective
Youth-guided and family driven services
Youth and family partnerships

33. Developmental & Resiliency Focus
Resource and support building
Risk reduction & asset promotion
Facilitation of accommodations across life domains
Build developmental skill sets
Assess and address for trauma

34. Multidimensional Assessment
Symptom Patterns and Diagnoses
Contextual Functioning: Degree of functional impairment per life domain
Developmental and Cognitive Functioning: (cognitive functioning, emotional, & behavioral maturity)
Risk and Recovery Environments: Environmental risk and recovery conditions (e.g. trauma, safety, negative influences, family conflict, poverty)

35. Contextual Assessment
School
Informal Supports + +
Family - + -
Youth -
Peers
Community + + - - +
+ = Protective Factors -
- = Risk Factors
Copyright 2006, 2009
Center for Innovative Practices
Work

36. Comprehensive Treatment Matched to Need
Recovery &
Resiliency
ECOSYSTEMIC FUNCTIONING
BASIC SKILLS
BASIC NEEDS & SAFETY
Youth and Family Need Hierarchy (Shepler, 1991, 1999)

37. Polices that support IHBT implementation
Clear program LOS guidelines with procedures for continuing stay
Flexible work hours
Rotating coverage for on-call
Cell phones
Laptops
Safety policies for workers
Supervisor dedicated to the program
Reasonable productivity requirements

38. Risk Management IHBT programs require active risk management
Dedicated supervisor to IHBT team is an insurance policy
Protected clinical supervision time
Child and family teaming to share the risk
Assess for safety and risk with every family
Active safety planning
Proactive safety monitoring
Regular communication with system partners

39. Target Outcomes Increase functioning in major life contexts:
Living at home or in a permanent home setting
Attending and achieving at school/work
Reduced involvement in the JJ system
Reduced use/no use of substances
No new abuse or neglect
No new trauma
Participating in positive family, peer, and community life
Improved family recovery environment
Accessing resources and natural supports as needed to maintain gains and prevent recidivism
Youth’s lives are complex; compounded by fact they have multiple disorders
Multiple disorders;
Multiple contextual environments (family, neighborhood, peers, school, community)
Different developmental stages
Different learning styles and capacities
Varying levels of resources, supports, and assets
Varying degrees of risk

40. Training areas Family systems Risk assessment and crisis stabilization
Parenting skills and supports for children/adolescents with SED
Cultural competency
Intersystem collaboration and coordination
Trauma-informed care
Educational and vocational functioning
Strength-based assessment and treatment planning
Co-Occurring Disorders
Behavioral Health and Juvenile Justice
Ethics in IHBT
Supervising IHBT

41. Lessons Learned: IHBT Implementation Issues
Technical Assistance is needed to maximize effectiveness of IHBT
Agency/program level funding requires more than Medicaid
A uniform data collection system is necessary in order to provide timely clinical feedback and track quality improvement
Stakeholders/funders increasingly relying on data to make financial decisions
Multiple partners and multiple systems are needed to support implementation
High level training and ongoing coaching and monitoring of fidelity

42. Proven Formula Effective intervention practices and programs+
Effective implementation practices
= Good outcomes for children and their families
No other combination of factors reliably produces desired outcomes for children, families, and caregivers
NIRN
The usability of a program has little to do with the weight of the evidence regarding program outcomes
Evidence on effectiveness helps us select what we want implement
Evidence on outcomes does not help us implement the program

43. The best is to have a strong program implemented well
Implementation is Essential (Reduction in Recidivism from Control Group Rates)
The best is to have a strong program implemented well
The effect of a well implemented weak program is as big as a strong program implemented poorly
Thus one should optimally pick the strongest intervention that one can implement well
Source: Adapted from Lipsey, 1997, 2005

44. ODMH committed to adding IHBT to Medicaid service menu by FY ‘13
IHBT workgroup completed its review
ODMH conducting rate setting exercise
Next Steps: Prepare SPA and submit to CMS
Training and roll out
Current IHBT status
Approximately 20+ certified IHBT sites
16 MST teams for 10 counties
Other non-certified in home programs
So, where is Ohio on IHBT?

45. More Information: Patrick Kanary patrick.kanary@case.edu
Richard Shepler
Center for Innovative Practices
Begun Center for Violence Prevention, CWRU