1. 2011 System of Care Community Training of the Federal Substance Abuse and Mental Health Services Administration, Chicago, Illinois. Presented by:.Arabella Perez, LCSW Director THRIVE Initiative Douglas Patrick, JD, LCSW Children’s Systems Manager Children’s Behavioral Health Services DHHS Making Change Last: Taking a Trauma-Informed System from Theory to Continuous Improvement Brianne Masselli, BS Manager Training and Continuous Quality Improvement THRIVE Initiative Laurie Cavanaugh Regional Parent Support Coordinator G.E.A.R. Parent Network

2. working together for a brighter tomorrow Overview Introduction to Panel Agenda for the session History of THRIVE Who’s in the room

3. working together for a brighter tomorrow Today’s Agenda 1.Trauma-informed principles and the difference between trauma-informed and trauma specific service. 2.Assessing and measuring whether services are trauma- informed. 3.Identifying how to provide technical assistance with stakeholders based on assessment outcomes. 4.How youth and family define quality. 5.How DHHS, family, and youth sustain the system of care through continuous quality improvement.

4. working together for a brighter tomorrow What is Trauma? 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 A trauma is a psychologically distressing event that is outside the range of usual human experience. Trauma often involves a sense of intense fear, terror, and helplessness. Trauma should not be confused with stress. Stress is an inevitable component of everyone's life. Trauma is an experience that induces an abnormally intense and prolonged stress response. Child Traumatic Stress is when children and adolescents are exposed to traumatic events or situations, and that exposure overwhelms their ability to cope.

5. working together for a brighter tomorrow What is the Thrive Initiative The Thrive Initiative is a Phase V (2005) Federally Funded System of Care that seeks to educate and transform services We provide education on the System of Care principles and how to enhance service systems though the use of “Trauma- Informed” theory Trauma-Informed is our 4 th SOC principle!

6. working together for a brighter tomorrow Why Does it Matter? We can care clinically but why should we as a larger community care about trauma and how it impacts all of us in some way or another?  Trauma can have intergenerational, historical and societal impacts  It is often self-perpetuating and differentially affects the more vulnerable  It can be stigmatizing  Preventable health and human event with enormous societal cost  Evidence – Adverse Childhood Experiences and local research

7. working together for a brighter tomorrow OBJECTIVE #1 Trauma-Informed Principles Trauma-Informed vs. Trauma Specific services

8. working together for a brighter tomorrow Trauma-Informed In a Nutshell If you remember nothing else, remember this! Instead of asking “what is wrong with you?” a trauma-informed approach asks “what has happened to you?” Trauma-Informed is about adopting a Universal Precautionary Approach Roger Fallot and Maxine Harris (eds.), Using Trauma Theory to Design Services Systems

9. working together for a brighter tomorrow The Trauma-Informed Principles * Because trauma affects how people approach services service systems need to consider…. 1.Safety 2.Trustworthiness 3.Choice 4.Collaboration 5.Empowerment 6.Language Access and Cultural Competency * See Handout on Principles

10. working together for a brighter tomorrow Traditional versus Trauma-Informed * Understanding of Trauma Understanding of the child/youth survivor Understanding of services Understanding of the service relationship * See Handout on Differences

11. working together for a brighter tomorrow OBJECTIVE #2 Assessing whether services are trauma-informed

12. working together for a brighter tomorrow Why Assess? To improve the entire mental health system for youth and families. To identify areas where agencies are doing well, and to guide next steps for making the system even more trauma-informed.

13. working together for a brighter tomorrow Assessing Trauma-informed Approach in Maine Trauma-Informed Agency Assessment (TIAA) ©  A two-pronged assessment: measures 6 key trauma elements across multiple perspectives  Three tools developed to gauge the level of trauma-informed approach to services Agency Staff Self-Assessment Family Questionnaire Youth Questionnaire

14. working together for a brighter tomorrow Involving Youth and Family PhaseRole of Youth and FamilyHow? Youth and Family... Planning Create framework and questions; provide feedback and suggestions....identified what is most important to them....made sure key components include youth and family priorities....drafted definitions and questions. Pilot Testing Test and refine questions, methods and framework....helped an evaluator to conduct key informant interviews....brainstormed ways to reach family and youth....pilot tested final data collection instruments....suggested changes. Implementation Ensure data collection is family and youth friendly. Review responses and suggest best practices to ensure family/youth are reached. Interpret results....provided technical assistance to agencies....helped youth/families respond to the assessment....reviewed quarterly report on the number of responses....made suggestions based on report....reviewed final data results.

15. working together for a brighter tomorrow Pilot Testing Two agencies agreed to pilot the tool Paired teams (evaluator and youth/family) conducted interviews with staff, family members and youth Interviewers scored responses according to standards articulated by key stakeholder group

16. working together for a brighter tomorrow Statewide Implementation Statewide contract language mandated implementation of TIAA Depth and breadth of tool scaled back Data collection methodology simplified  Web-based and paper-based assessments

17. working together for a brighter tomorrow Initial Findings Process Findings  People (still) like paper  Response rates depend on agency commitment Periodic reports on numbers received boosts responses Evaluation Findings  Youth perceptions of TI approach consistently lower (empowerment, trust and safety)  Staff feel their agencies not committed to TI approach

18. working together for a brighter tomorrow OBJECTIVE # 3 Data Driven Technical Assistance

19. working together for a brighter tomorrow Statewide CQI Plan Conduct TIAA Assessment Prioritize Areas of Need Create Continuous Quality Improvement Plan for DHHS Contract Implement CQI Plan / Plan Do Study Acts Technical Assistance from Thrive Consultants/ Use of “Guide to Trauma- Informed Organizational Development” Additional Technical Assistance as needed Agency and DHHS Review Results Guidance from DHHS Regional Coordinator leads to initial contact with Thrive

20. working together for a brighter tomorrow Agency Report: TCMHS Agency ResultsStatewide Results Trauma-informed Domain Agency (N = 107) Family (N = 50) Youth (N = 24) AgencyFamilyYouth I. Physical and Emotional Safety73%83%73%82% 84% 77% II. Youth Empowerment, Choice and Control 78%x66%78% x 70% II. Family Empowerment, Choice and Control 80%77%x82% 80% x III. Trauma Competence75%81%74%70% 85% 74% IV. Trustworthiness84%83%76%86% 87% 77% V. Commitment to Trauma-informed Philosophy 73%xx65% x x

21. working together for a brighter tomorrow Example Technical Assistance and CQI May want to focus on one specific domain at a time Consider feasibility, impact and available resources Identify goal, specific steps to reach each goal, resources needs to achieve each goal, realistic timeframe for achievement of each goal Goal: Increase Family rating on: empowerment, choice and control Options: 1. add questions to employee survey, 2. involve consumer advisory board, 3. incorporate more training into staff orientation, 4. change hours, days of operation (add evening, week-end hours)

22. working together for a brighter tomorrow Technical Assistance and Training Trauma-Informed System of Care Crosswalk – best practice guidelines Family and Youth as Co-trainers Identify Agency Trauma-Informed SOC Champions Continuous Quality Improvement Feedback

23. working together for a brighter tomorrow OBJECTIVE # 4 How do Family and Youth Define Quality?

24. working together for a brighter tomorrow Hearing from Maine Families and Youth Youth and Family have a seat with the CQI Large Group Issues/Topics discussed Youth and Family meet in smaller group and brainstorm Results/ideas then reported to the CQI for further discussion Other smaller sub groups have been formed; youth and family group members are dispersed throughout these groups

25. working together for a brighter tomorrow STRUCTURE CQI Data/Resources Sub Group Residential Quality Sub Group Quality Measures Sub Group Youth and Family Group Youth Advisory Group

26. working together for a brighter tomorrow Sustaining the Trauma-informed Approach Statewide Assessment  Contractual Obligation  Biennial Administration Continuous Quality Improvement (CQI)  CQI Plan Required  Ongoing Technical Assistance and Training

27. working together for a brighter tomorrow The Contract Language System of Care Principles: 17.The goal of DHHS is that Providers of Children’s Behavioral Health Services are integrated in a Trauma Informed System of Care. Providers will promote the Federal Substance Abuse and Mental Health Services Administration’s (SAMHSA) System of Care Principles of 1) Family Driven, 2) Youth Guided, and 3) Culturally and Linguistically Competent care. These three System of Care Principles are described at http://systemsofcare.samhsa.gov/. 18.An additional principle for a Maine’s Children’s Behavioral Health System of Care is that it is Trauma Informed. 19.By January 1, 2010, the Provider shall administer a system of care self Assessment Tool approved by the Department that addresses the principles referenced in paragraphs 18 and 19 herein. 20.By January 1, 2011, Provider, in collaboration with Children’s Behavioral Health Services, will include in its Quality Improvement Plan developed under Rider “A” areas of need identified by the Assessment Tool and plans to meet those needs www.maine.gov/dhhs/purchased-services/contract-2010/rider-e/RIDER-E-CS.pdf

28. working together for a brighter tomorrow State CQI Efforts

29. working together for a brighter tomorrow Conclusion and Questions Thank you all for your time! Presenters can be contacted as follows:  aperez@tcmhs.org aperez@tcmhs.org  bmassell@tcmhs.org bmassell@tcmhs.org  douglas.patrick@maine.gov douglas.patrick@maine.gov  lcavanaugh@crisisandcounseling.org (GEAR) lcavanaugh@crisisandcounseling.org

30. working together for a brighter tomorrow Conclusion, Resources and Contact Information www.thriveinitiative.org www.gearparentnetwork.org www.nctsn.org www.chadwickcenter.org www.acestudy.org http://mentalhealth.samhsa.gov/nctic/ For more information please contact aperez@tcmhs.orgaperez@tcmhs.org or www.thriveinitiative.orgwww.thriveinitiative.org