Emqff wraparound institute june 2012 child and adolescent characteristics outcomes and wraparound...
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Child and Adolescent Characteristics, Outcomes, and Wraparound Fidelity:
Results from Eight California Programs
Abram Rosenblatt, Michelle Coufal, Kate Cordell, Elisha Heruty,
Catherine Aspiras, Mary Ann WongEMQ FamiliesFirst
2
Presentation Overview
• Youth Profile and Core Outcomes• Child and Adolescent Needs and Strengths
(CANS) Outcomes• Wraparound Fidelity Index (WFI-4) Profile and
Outcomes• Longitudinal Outcomes
3
Number of Youth Served
Total Number of Youth Served
in Wraparound: 4,43242%
24%
21%
3%
11%
Bay Area Capital Central Inland EmpireLos Angeles
4
Number of Youth Served in CY11
Total Number of Youth Served in
Wraparound in CY11: 1,158
28%
19%
6%
24%
24%
Bay Area Capital Central Inland EmpireLos Angeles
5
Youth’s Profile• Average Age at Admission: 14 years• 61% Male; 39% Female• Youth’s Ethnicity
Native American 1%
Other 2%
African American21%
Asian American/Pacific Islander
3%
Latin American30%
Caucasian 40%
6
Youth’s Profile in CY11• Average Age at Admission: 14 years• 60% Male; 40% Female• Youth’s Ethnicity
Native American
1%Other
1%
African American
17% Asian American/
Pacific Islander
2%
Latin American46%
Caucasian 34%
7
Primary Diagnosis at Admission
6%
48%
35%
2%9%
0%
20%
40%
60%
80%
100%
Adjustment MoodDisorder
DisruptiveBehavior
Psychotic Other
8
Primary Diagnosis at Admission for Youths Served in CY11
9%
39%44%
1%7%
0%
20%
40%
60%
80%
100%
Adjustment MoodDisorder
DisruptiveBehavior
Psychotic Other
9
Living Situation at Admission
55%
16%
0.2% 2%
24%
1% 2%0%
20%
40%
60%
80%
100%
Home
Foster Family
Hospital
Justice
Residential
Shelter/Homeless
Other
10
Living Situation at Admission for Youths Served in CY11
60%
23%
0% 2%15%
0.3% 0.3%0%
20%
40%
60%
80%
100%
Home
Foster Family
Hospital
Justice
Residential
Shelter/Homeless
Other
11
Outcomes for Discharged Youth
12
Profile of Discharged Youth
• Number of Youth Discharged from Wraparound:
3,893• Average Length of Stay: 12 months
13
Profile of Youth Discharged in CY11
• Number of Youth Discharged from Wraparound:
607• Average Length of Stay: 11 months
14
Living Situation: Admit vs. Discharge
67% 73%
29%23%
3% 3% 0.3% 1%
0%
20%
40%
60%
80%
100%
Community Facility Other Unknown
Admit Discharge
15
Living Situation: Admit vs. Discharge for Youth Discharged in CY11
82%80%
17% 17%
1% 1% 0.4% 2%
0%
20%
40%
60%
80%
100%
Community Facility Other Unknown
Admit Discharge
16
Core Outcomes for Discharged Youth
80% 82% 82%
0%
20%
40%
60%
80%
100%
In Home In School Out of Trouble
17
Core Outcomes for Youth Discharged in CY11
81% 83% 84%
0%
20%
40%
60%
80%
100%
In Home In School Out of Trouble
18
Longitudinal Core Outcomes
77%85%
76%
0%
20%
40%
60%
80%
100%
In Home In School Out of Trouble
19
Why the CANS?
• Item Level Tool• Items translate immediately into action levels • It is about the youth, not about the service • Cultural and developmental contexts are considered
before establishing action levels • It is about the ‘what’, not about the ‘why’
• 30 day window for rating unless otherwise specified
20
CANS Overall Reliable Change Index (RCI)
21
CANS Overall RCI by Program
22
CANS Life Domain Functioning Domain RCI by Program
23
CANS Child Strengths Domain RCI by Program
24
CANS Caregiver Strengths and Needs Domain RCI by Program
25
CANS Child Behavior and Emotional Needs Domain RCI by Program
26
CANS Child Risk Behaviors Domain RCI by Program
27
What is the WFI-4?
• Measures implementation of wraparound process• Set of interviews – Facilitator, Caregiver, and Youth
– 40 items for Facilitator and Caregiver– 32 items for Youth
• Confidential interviews w/multiple respondents unique perspectives
28
Interview Detail:
• 671 facilitators interviewed
– 40.3 minutes average time
• 522 caregivers interviewed
– 39.1 minutes average time
• 305 youth interviewed
– 34.3 minutes average time
Summary of Respondents
Administration Time Frame: January 2008 – January 20121,498 interviews from 671 families
8 traditional wraparound programs in 7 counties:
•Santa Clara•Sacramento•Nevada•Yolo•Fresno•San Bernardino•Los Angeles
29
Demographics of WFI Youth• Average Age at Admission: 13.5 years• 57% Male; 43% Female• Youth’s Ethnicity
Caucasian 38%
Latin American41%
Asian American/Pacific Islander
3%
African American17%
Other 1%
Native American 1%
30
Primary Diagnosis at Admission for WFI Youth
10%
45%39%
1%6%
0%
20%
40%
60%
80%
100%
Adjustment MoodDisorder
DisruptiveBehavior
Psychotic Other
31
Living Situation at Admission for WFI Youth
54%
19%
0% 1%
24%
0.3% 0.3%0%
20%
40%
60%
80%
100%
Home
Foster Family
Hospital
Justice
Residential
Shelter/Homeless
Other
32
Outcomes for Discharged WFI Youths
33
Living Situation: Admit vs. Discharge for WFI Youth
70%81%
29%
17%
1% 1% 0.3% 1%
0%
20%
40%
60%
80%
100%
Community Facility Other Unknown
Admit Discharge
34
EMQ FF vs National Data: Overall Fidelity
83%77%
87%83% 80%
75% 78%73%
0%
20%
40%
60%
80%
100%
Combined Facilitator Caregiver Youth
EMQ FF National Mean
35
EMQ FF vs National Data : Fidelity Scores by Phase
82%76%
86%76%
88%81%
76%69%
0%
20%
40%
60%
80%
100%
Engagement Plan Development Implementation Transition
EMQ FF National Mean
36
EMQFF Phase Scores by Program
81%86%
89%
78% 80%
87%90%
78%84%85%87%
76%
85%83%87%
76%81%
89%90%
75%78%
87%92%
80%84%
87%87%
75%81%
78%83%
70%
0%
20%
40%
60%
80%
100%
Program 1 Program 2 Program 3 Program 4 Program 5 Program 6 Program 7 Program 8
Engagement PlanningImplementation Transition
37
EMQFF Principle Scores by Program
91%
70%70%
94%89%
94%
72%73%
95%
82%
92%
80%
67%
92%
79%
90%
78%
65%
92%
79%
94%
72%72%
96%
82%
90%
76%
82%
93%87%
91%
76%
67%
92%
82%
91%
72%
64%
89%
69%
0%
20%
40%
60%
80%
100%
Program 1 Program 2 Program 3 Program 4 Program 5 Program 6 Program 7 Program 8
Family Voice and Choice Team-BasedNatural Supports CollaborationCommunity-Based
38
EMQFF Principle Scores by Program continued
97%
78%
91%
82%79%
97%
78%
90%
81%83%
95%
78%
91%85%
72%
96%
74%
86%84%
76%
98%
80%
89%
82%83%
95%
78%
89%86%
76%
96%
76%
90%85%
76%
92%
70%
81%86%
66%
0%
20%
40%
60%
80%
100%
Program 1 Program 2 Program 3 Program 4 Program 5 Program 6 Program 7 Program 8
Cultural Competence IndividualizedStrength-Based PersistenceOutcome- Based
39
Average Total WFI Scores By Program
EMQ Wraparound Program Average Total WFI Score
Program 1 84%
Program 2 85%
Program 3 83%
Program 4 82%
Program 5 85%
Program 6 85%
Program 7 83%
Program 8 78%
40
Core Outcomes for Discharged WFI Youth
80%84%
90%
0%
20%
40%
60%
80%
100%
In Home In School Out of Trouble
41
Longitudinal Core Outcomes for WFI Youth
85% 88% 83%
0%
20%
40%
60%
80%
100%
In Home In School Out of Trouble
42
Data Implications
• Further studies employing the WFI and CANS on Outcomes
43
WFI and CANS Outcomes
• Is our fidelity associated with our outcomes?
• Which fidelity elements are more strongly associated with which outcomes?
44
WFI & CANS Outcomes
• 324 clients with two CANS Outcomes at least 6 months apart and a WFI at 6 months of service
45
WFI & Life Domain Functioning CANS
• Improved or Declined CANS groups determined by Reliable Change Index (RCI)
46
WFI & Child Strengths CANS
• Improved or Declined CANS groups determined by Reliable Change Index (RCI)
47
WFI & Caregiver Strengths/Needs CANS
• Improved or Declined CANS groups determined by Reliable Change Index (RCI)
48
WFI & Child Behav. & Emo. Needs CANS
• Improved or Declined CANS groups determined by Reliable Change Index (RCI)
49
WFI & Child Risk Behaviors CANS
• Improved or Declined CANS groups determined by Reliable Change Index (RCI)
50
WFI and CANS Outcomes
• Which source of fidelity scores are more strongly associated with improved outcomes?
51
WFI-Facilitator Source & CANS
• Facilitator fidelity scores are strongly associated with CANS outcomes scores.
52
WFI-Caregiver Source & CANS
• Caregiver fidelity scores are lower than facilitator fidelity scores.
53
WFI-Youth Source & CANS
• Youth fidelity scores are lower than facilitator scores and exhibit reversal of pattern in some elements for association between fidelity and outcomes.
54
WFI and CANS Outcomes
• How is fidelity at different phases of the program associated with CANS outcomes?
55
WFI by Phase & CANSThe group of clients who only
declined in CANS domains had
significantly lower fidelity scores at
the:
• Planning (p=0.04),
• Implementation (p=0.005)
• Transition (p=0.001)
phases of the Wraparound program
as compared to the group of clients
who improved in at least one CANS
domain.
56
WFI and CANS Outcomes
• Focused Quality Improvement:– In what fidelity elements should we focus our energies in order
to maximize improvement in Child Behavioral and Emotional Needs outcomes?
• Measurable Quality Improvement– How much improvement (i.e., what increased percentage of kids
would have reliable improvement) would we expect to see if we brought all of these elements in our programs up to ‘high fidelity’
57
Improving Fidelity and CANS Outcomes • There were 317 clients with a
CANS Child Behavioral and Emotional Needs score which could be reliably improved from Time 1 (GTE RCI of 2.2).
• Overall, 45.1% of clients improved between Time 1 and Time 2.
• Programs with higher fidelity in certain elements resulted in better outcomes.
Order of elements determined by classification and regression tree (CART).
45.1 %40.1 %14.8 %
High fidelity (>=85%) for Element 5 (Community Based) = YES
47.2 %38.1 %14.8 %
High fidelity (>=85%) for Element 6 (Culturally Competent) = YES
48.8 %36.9 %14.3 %
High fidelity (>=85%) for Element 9 (Persistent) = YES
52.3 %36.7 %11.0 %
High fidelity (>=85%) for Element 10 (Outcomes Based) = YES
56.5 %37.0 %6.5 %
Child Behavior and Emotional Needs
176
Improved
No Change
Declined
Child Behavior and Emotional Needs
168
Improved
No Change
Declined
Child Behavior and Emotional Needs
109
Improved
No Change
Declined
Child Behavior and Emotional Needs
46
Improved
No Change
Declined
Improved
No Change
Declined
Child Behavior and Emotional Needs
317
58
WFI and CANS Outcomes Summary
• Our fidelity scores are associated with our CANS outcomes
• Facilitator fidelity scores are more strongly associated with CANS outcomes
• The data suggests that focused quality improvement in fidelity will result in a measurable improvement in CANS outcomes
59
Challenges
New staff New Measure Implementations
Difficult populations Language barriers
Ratio of certified interviewers to interviewees Relatively low response rates
60
Lessons Learned
Program buy-in Work with Wrap teams Use EMQ FF language certified employees
61
Future Directions
62
Future Directions
• Build on Initial Analyses• Translate to Clinical Staff• Consider Fidelity Intervention Options• Ongoing WRAP Fidelity Feedback (Bruns)
• Build Ongoing Reporting Mechanisms• Link to Quality of Care and Key Performance Indicators
63
Q & A
64
References
• Bruns, E. (nd). Wraparound Fidelity Assessment System. Retrieved from Wrap Info website: http://depts.washington.edu/wrapeval/WFI.html
• Lyons, J. Child and Adolescent Needs and Strengths. Retrieved from Praed Foundation website: http://www.praedfoundation.org/About%20the%20CANS.html
• Wraparound Evaluation & Research Team. The Wraparound Process. Retrieved from http://depts.washington.edu/wrapeval/approach.html