System of Care and New Hampshire’s Model for Family- and

System of Care and New Hampshire’s Model for Family- and Youth-Driven Wraparound Overview February 8, 2017

Presenters Daryll Tenney, FAST Forward Program Manager, DHHS Adele Gallant, Children's Behavioral Health Administrator, DHHS Laurie Foster, Family and Community Support Specialist, NAMINH Christine Alibrandi, Director, NH Children’s Behavioral Health Collaborative JoAnne Malloy, Clinical Assistant Professor, NH Institute on Disability, UNH

We are grateful to. Pat Miles, Mary Jo Meyers, and Verneesha Banks (WRAP Milwaukee) The NH Department of Health and Human Services The NH Wraparound Workgroup

Agenda Introduction System of Care Wraparound: Key features, values and context for implementation . FAST Forward project in New Hampshire NH’s Wraparound Practice Model NH’s System of Support for Wraparound

Jane Knitzer “Unclaimed Children,” 1982 “At the Schoolhouse Door,” 1990

“A System of Care for Severely Emotionally Disturbed Children &. Youth” Stroul & Friedman, 1986 Services are fragmented Solution: Programs, services, mechanisms, eligibility, finances, organizational structures are coordinated and aligned Services are inadequate (too many children/youth) end up in expensive, restrictive placements (state hospital, residential care, detention). Solution: A continuum of services including intensive, in-home supports, and service sin less restrictive settings

Children’s Mental Health Initiative (CMHI) The Substance Abuse and Mental Health Services Administration (SAMHSA) has funded over 250 System of Care grants since 1993. The national evaluation found 1. Positive outcomes for children and families 2. Improvements in systems and services 3. Better investments with limited resources (Stroul & Boyce, 2015)

Results of National Evaluation of SOC projects . (Stroul & Boyce, 2015)

System of Care Framework Stroul, B. System of Care Framework Presentation. NH. 2010.

System of Care is “A spectrum of effective, community-based supports, that is organized into a coordinated network, builds meaningful partnerships with families and youth, and addresses their cultural and linguistic needs, in order to help them to succeed at home, in school, in the community, and throughout life” (Stroul & Friedman, 2010)

Breaking Down Silos For NH’s Top-Tiered Children in Need of Mental Health Services NH’s SOC Service Array CMHC Services DCYF Services The braiding of services and funding sources will result in children being served more effectively in their home communities, with enhanced services from both systems.

System of Care Core Values 1. Family driven and youth guided, with the strengths and needs of the child and family determining the types and mix of services and supports provided. 2. Community based, with the locus of services as well as system management resting within a supportive, adaptive infrastructure of structures, processes, and relationships at the community level. 3. Culturally and linguistically competent, with agencies, programs, and services that reflect the cultural, racial, ethnic, and linguistic differences of the populations they serve to facilitate access to and utilization of appropriate services and supports and to eliminate disparities in care.

Transformation Reactive, crisis oriented approach Focus on restrictive settings Children out of home Centralized authority Focus on prevention/ early intervention Focus on least restrictive settings Children within families and home communities Community based ownership 17

Transformation Creation of dependency Identified child or youth only focus Needs/deficits assessments Fostering empowerment and self-efficacy Family as focus Strengths based assessments

Transformation Families and youth as “problems” Cultural passivity Highly professionalized, expert provider models Families and youth are driving the process Cultural competence Use of multiple natural and informal supports

Transformation Child and family “fit into” existing services Input-focused accountability Funding tied to programs, eligibility silos Individualized or wraparound approach Outcomes/results based accountability Funding tied to needs of families

Pause--- questions or comments?

What is Wraparound? Based on a clear set of values and principles Highly structured planning process Family and youth driven Capitalizes on family strengths, culture, and values Solution focused Dynamic teams and supports (public, private, and natural) Includes family/youth peer support Led by a trained facilitator

Wraparound is not: A specific set of services offered A typical team meeting Any meeting held without family or youth An immediate or quick solution A crisis intervention or response A standing interagency team

How Wraparound Works SHORT TERM OUTCOMES High-quality facilitation that is individualized and: Family- and youthdriven Culturally and linguistically competent Community-based Strengths-based Focused on outcomes Family and youth peer support Identification of underlying needs Improved engagement in shared work Improved service coordination Services and supports are based on strengths INTERMEDIATE OUTCOMES More Effective Services Greater satisfaction with services Improved family, youth and team member self-efficacy Increased capacity for coping and problem-solving Team goals are being achieved LONG-TERM OUTCOMES Improved emotional and behavioral functioning (youth and caregiver) Improved functioning in home, school, and community Achievement of Team mission Improved resiliency and quality of life

Peer-to-Peer Support In any healing process it is vital to have a peer who has the lived experience and perspective offer hope by: Helping to reduce the feelings of isolation Supporting the youth and family in times of high stress Helping the youth and family to navigate the various and complex systems they use Encouraging the family and youth to express their needs Conveying a sense that things will get better

Wraparound in the System of Care Context MOST INTENSIVE NEEDS Family- and Youth-Driven Wraparound Supports for FEW Supports and interventions for children, youth in high-risk groups, and their families Education, Prevention, Health Promotion Supports for SOME Supports for EVERYONE LEAST INTENSIVE NEEDS

Values and Principles: NH’s Wraparound Model

FAST Forward NH Project 2012-16 4-year System of Care project funded by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) Goals: Establish family-/youth-driven wraparound in NH Establish a funding, policy, and systems administration to support System of Care and wraparound development in NH

The NH Bureau for Children’s Behavioral Health Coordinates Implementation of Wraparound Family/Youth Level: Referrals, eligibility, and payment process Accepts referrals and screens for eligibility of family, self or school direct referrals when one has not yet been done (using NH CANS) Service utilization management, Quality improvement, Information technology-web based system. Measures fidelity of implementation, outcomes, process and service utilization.

NH Wraparound Framework Hello: Initial contact; engagement of family; getting to know family and building rapport Help: Agreeing on, providing, and delivering a range of interventions, services, & supports Healing: Modifying initial helping activities to produce family report of healing Hope: Future oriented activities designed to sustain family’s experience of hope Framework Hello Help Healing Hope June 14 [email protected]

NH Wraparound Critical Roles: Wraparound Coordinators NH Wraparound Coordinators: Works with families to establish wraparound teams, hold initial meetings with families, facilitates wraparound meetings and performs care coordination, facilitates referrals to other supports and services, develop crisis plans, facilitates the development of the family’s vision and plan of care, collaborates with Family and Youth Peer Support Providers, collects data and completes required documentation.

Family History 6 year old female diagnosed with Attachment Disorder & Anxiety Child adopted through child protection services by the paternal grandmother at 2 years old, after severe abuse and neglect was reported. Child had difficulty managing behaviors at home and school. Often would get suspended from school and sent home for throwing chairs, desks, breaking computers, hitting teachers, biting, refusal to do work, distracting other students. Challenges include a difficult home situation and Primary Caregiver fatigue, as Mom struggled to manage her own self-care.

Referral to FAST Forward Referral to FAST Forward program was made by assigned Post Adopt Services Worker from Child Protection Office. Mom was overwhelmed with the youth’s behavior and had limited supports. Worker stated that she was in need of someone who could help to coordinate a Wraparound team to assist the family and feel a part of their community. Before 1st Wraparound Team meeting: Mom communicated that having a positive relationship with the school was important to her.

FAST Forward Process Coordinator met with family: Created Family Vision – “To be seen as being capable, loving, and loved” Developed functional strengths “Likes to be close to others and uses nurturing skills to help others” “Is very attentive when there is a trusting relationship who is close” “Likes to be a part of solutions that are made about her” Identified underlying needs to why family was seeing behaviors “Mom: I need to feel like a valuable person and confident as a parent.” “Child: I need to know I don’t need to be scared.”

1st Wraparound Team Meeting Team consisted of: School social worker, Post-Adopt Worker, FCSS, Family friends (natural supports), Community mental health therapist and case manager. As a team, brainstormed strategies to help to meet underlying needs identified. Strategies include: Addition of In-Home Family Support, focusing on relationship building between Mom and youth and safety Improve communication with school

NH System of Care Individuals in NH FAST Forward have access to an expanded array of reimbursable service and natural supports: DCYF Reimbursable Services Additional Services: Wraparound Facilitation Peer Support Flexible Funds Natural Supports and Community Based Services Mental Health Reimbursable Services

Pause- any comments or questions?

Today: Care Management Entity (CME) -NFI NFI as CME: 1) Implementation of high-quality NH Wraparound; 2) Service provider coordination across agencies and providers; 3) Intensive care coordination; 4) Home- and community-based services and peer supports as alternatives to costly residential and hospital care for children and adolescents with severe behavioral health challenges; 5) That NH Wraparound Coordinators receive required training and coaching; 6) Family and youth peer to peer support are an integral part of NH Wraparound; 7) Manages costs of NH Wraparound (income and expenses). (Derived from: U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, 2011)

Care Management Entity (cont.) NFI as CME System Level: Develops provider network to provide SOC service array with Managed Care Organizations (MCOs) – utilizing current DCYF/Bureau of Behavioral Health (BBH) providers. Develops/joins regional teams to assess capacity and barriers and community partnership –(Family Organizations). Manages provider contracts. Employs and supervises Fast Forward NH Wraparound Coordinator.

Role of the Wraparound Facilitator/Coordinator Care Coordination- link to services including funding and reimbursement Care Management Entity Wraparound Facilitator/Coordinator Family, Youth, and Team Family-Driven Planning and Team Facilitation

Critical Roles Family Peer Support Partner Member of the family team Supports and coaches the family Assists the family to identify, prioritize, and articulate their needs Ensure that the family’s culture is respected Help the family learn how to navigate and advocate within the system Fosters a sense of resilience and hope within the family Provide information on resources Help connect to natural supports and resources

FAST Forward Expand “Family to Family” Support, Education and Leadership Training SUPPORT 1:1 Time Limited Support GroupCommunity Facebook Page EDUCATION PMC Family Education Program Webinars Annual Conference LEADERSHIP TRAINING PMC Teacher Support Group Facilitator “Life Interrupted” -Speaker “It’s Your Move”-Advocacy Identify, recruit and provide on-going technical assistance to family leaders serving on a wide range of activities on the local, state and national levels.

Critical Roles: Youth Peer Support Specialist (YPSS) Provides support with lived experience Meets with youth regularly Uses personal experience to develop a meaningful relationship Ensures the youth feels connected and understood Empowers them to identify and focus on actualizing their own goals: Personal growth, wellness, resilience, and self-efficacy Supports youth to advocate for own needs through effective communication Connects to supports and services Equal relationship where all support must be mutually given and accepted

Youth Leadership and Development of Youth Peer Support Granite State Federation of Families for Children’s Mental Health Individual Level: Training and Support System Level: Training and Support Training for youth to drive Youth Move Orientation, their own planning Focus Groups Group Forums for Individual Support and Connections (YM and RENEW Facebook) Leadership Youth Voice and Perspective to Systems Change Efforts “Strategic Sharing” Conference Planning and “What Helps What Co-Hosting: Youth Track Harms”- YM National Development Social Marketing Initiative Development of 1:1 Youth Training and Recruitment Peer Support Model of Youth for Action in Systems Change Support and technical assistance to emerging youth leaders across systems

Training and Coaching Wraparound Coordinators must complete core training elements and shadow an experienced coordinator Coaching is critical to build and maintain high-quality fidelity to the model. Frequent coaching meetings (weekly to start) – group and individual, focused on skill building, using a combination of data, structured observation, and prescribed tools. Coaching is focused on the practice, not the individual family or youth. Coaches observe, consult, and provide structured feedback to support facilitators specific to the model elements.

Data Collection Document or Measure New Hampshire Wraparound Plan of Care and Benchmarks Crisis Safety Plan Timing Every Team meeting Child Assessment of Needs and Strengths (CANS) Quarterly Outcome Rating Scale Most Family Meetings Wraparound Coordinator Monitors coordinators/coach youth/family progress over outside of the Team time meeting At the end of every Wraparound Coordinator Monitor and feed back to coordinators/coach youth/family Team meeting perceptions of team meeting process over time Team Meeting Rating Scale Wraparound Fidelity Index Administered by Purpose NH Wraparound Keeps team focused on goal attainment and documents Coordinator the process Reviewed every team Wraparound Coordinator Provide a record of when crisis strategies were activated meeting and the results Every 6 months NH Bureau of Children’s Assess youth/family needs and strengths, and measure Behavioral Health or progress and outcomes Wraparound Coordinator NH Bureau of Children’s Behavioral Health Monitor overall fidelity to wrap principles from multiple perspectives Facilitator Review Form Wraparound Coach Monitors fidelity to wrap principles in team meetings Plan of Care Review Form Document Review Measure Wraparound Coach NH Bureau of Children’s Behavioral Health Identifies quality of wraparound process Assesses that the documentation reflects the NH Wraparound values and principles Once per youth or family

Fast Forward Outcomes- National Outcome Measures

CBHC and Its Strategic Plan Strategic Framework for Expanding the System of Care Approach 1. Implementing Policy, Regulatory, and Partnership Changes 2. Developing or Expanding Services and Supports Based on the SOC Philosophy and Approach 3. Creating or Improving Financing Strategies 4. Providing Training, Technical Assistance, and Workforce Development 5. Generating Support

Questions?

More Information and Resources NH Children’s Behavioral Health Collaborative: http://www.nh4youth.org/ Institute on Disability/UNH Wraparound portal: https://iod.unh.edu/projects/nh-childrens-behavioral-healthworkforce-development-network National Wraparound Initiative: http://nwi.pdx.edu/ System of Care, Substance Abuse and Mental Health Administration (SAMHSA), US Department of Health and Human Services: https://www.samhsa.gov/health-care-health-systemsintegration

Our Partners NH Department of Health and Human Services

Certificate of Attendance Write to [email protected] if you would like a certificate of attendance for this session. Put “Wraparound Webinar” in the subject line.