Why We Needed to Change JK Settlement: Arizona’s Roadmap

1. Wraparound Maine Symposium - Frank Rider Transforming Services for Children, Youth and Families through Systems Change: The Arizona Experience • Why We Needed to Change • JK Settlement: Arizona’s Roadmap • Pilots and Gurus: Figuring Out How to Change • Collaborative Voices and Structures • Operationalizing Principles • CQI: Structure, Process, Outcomes • Results to Date • Lessons Learned

2. Wraparound Maine Symposium - Frank Rider Why WAS Transformation Necessary? • Family Dissatisfaction • Fragmented Care • Inflexibility – Few Alternatives • Poor Outcomes

3. Rapidly Expanding EnrollmentJune 2000 - June 2006

4. Impetus for Change • Community Initiatives • Legislation – Executive Order • System of Care Grant Program • Litigation

5. J.K. Settlement Agreement Requires ADHS and AHCCCS to: • Improve frontline practice (CFT, best practices) • Enhance capacity to deliver needed services • Promote collaboration among public agencies and stakeholder participation • Develop quality management/improvement system

6. The Arizona Vision “In collaboration with the child and family and others, Arizona will provide accessible behavioral health services designed to aid children to: • achieve success in school • live with their families • avoid delinquency • become stable and productive adults Services will be tailored to the child and family and provided in the most appropriate setting, in a timely fashion, and in accordance with best practices, while respecting the child’s and family’s cultural heritage.” J.K. vs. Eden et al. No. CIV 91-261 TUC JMR, Paragraph 18

7. Wraparound Maine Symposium - Frank Rider The 12 Arizona Principles • Collaboration with the Child and Family • Functional Outcomes • Collaboration with Others • Accessible Services • Best Practices • Most Appropriate Setting • Timeliness • Services Tailored to the Child and Family • Stability • Respect for the Child and Family’s Unique Cultural Heritage • Independence • Connection to Natural Supports

8. J.K. Settlement Agreement Requires ADHS and AHCCCS to: • Invite and heed Family Voice • Improve frontline practice • Enhance capacity to deliver needed services • Promote collaboration among public agencies • Develop a quality management and improvement system • Six Year Term of Agreement

9. Arizona’s Early Innovators: 300 Kids Project “49. Defendant ADHS/DBHS shall initiate a 300 Kids Project.” • Will serve multi-agency children. • Sites to engage intensively in system improvement activity. 50. The sites will serve two purposes: • test strategies for providing behavioral health services according to the 12 Principles. • Serve as the first phase of a statewide effort to deliver services according to the Principles.

10. Wraparound Maine Symposium - Frank Rider Child and Family Team (CFT) Process Based on the Wraparound Approach: Service planning is family-centered, strength-based, highly individualized, culturally competent and collaborative across systems, promoting reliance on informal and natural supports in combination with formal services. Congruent with: • Family-Group Decision-Making (Child Welfare) • Team Decision-Making (Child Welfare) • Person-Centered Planning (Development Disabilities) • Individual Family Service Planning (IDEA - Part C)

11. Child systems join an Understanding While ADHS and AHCCCS were named as defendants in the J.K. lawsuit, Arizona’s remaining child-serving agencies (child welfare, children with special health care needs, early childhood, juvenile justice, and public school system) signed a Memorandum of Understanding, voluntarily and collectively embracing the Arizona Vision and the 12 Arizona Principles. The entities joined the Governor’s new Children’s Cabinet in 2003, and all have continuously reaffirmed their mutual commitments to this shared Vision and Principles since 2002.

12. CHANGING Organizational Thinking • Attitudes and Values • Language as an Organizing Framework • Leadership • Parent/Professional Partnerships • Early Innovators (Wraparound Maine, THRIVE System of Care)

13. Changing Organizational Thinking Attitudes and Values: The Relational Stance • From Problem to Competence • From Expert to Accountable Ally • From Professional Turf to Family Turf • From Teaching to “Learning With” William C Madsen, Collaborative Therapy with Multi-Stressed Families (1999)

14. Structure, Process, Outcomes • Structural Changes: • Covered Services • Funding • “Structural Elements” • Process Changes: • Training and Coaching, Consultants • Fidelity to Principles • Clinical Guidance Documents • Outcomes Improve: • Data-Driven Decision-Making

15. Structural Changes Necessary Arizona’s Covered BH Services • Medicaid, Behavioral Health, Licensing • Expanded Definition of “professional” • Expanded Definition of “family” • Expansion of Supportive Services • Capacity and Competency, or Quantity v. Quality

16. Structural Changes Necessary Funding • Variations in State Capitation Rates • Maximizing State Funding • Provider Contracting Methodology • Sustainability of Effort

17. Structural Accomplishment in AZ: • On January 29, 2003, Gov. Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide implementation • 01/31/2005: 13.5% of 34,000 with CFTs • 05/31/2006: 32% with CFTs • 12/31/2007: 51.6% with CFTs • Children involved with CPS & Juvenile Justice, residing in or at risk of placement in out-of-home care settings (RTC, TGH) are priority populations.

18. Process Changes Necessary Training and Coaching • Coaching to Support Training • Sequencing • Who Needs to Transform? • Costs/Investment • Retention/Regeneration Strategies

19. Process Changes Necessary Professional Roles • Transforming Roles – Relational Stance • Movement to Strengths Based • Values-Based Hiring Practices • Training and Re-training • Liability Myths • Shared Expertise with Families

20. Process Changes Necessary Clinical Guidance Documents • Operationalizing and Memorializing • Process for Development • Contract Requirements • Standardized Assessment (0-5, too) • Example: Child and Family Team PIP • Prior Authorization

21. Quality Management: Structure Examples: • Enrollment/Penetration (Latino youth? 0-3 y.o.?) • Number of functioning Child and Family Teams • Number of counties with cross-system protocols, agreements in place • Number of children placed outside of Arizona • Number of children placed out of home • Percentage of children in foster care with BH needs assessed beginning within 24 hours after removal

22. Quality Management: Structure • JK “Structural Elements” (monthly -> quarterly) • CFT Capacity • OOH Placements • Urgent BH Responses • Other Key Indicators (monthly) - • CFT Capacity by Provider • Rehab/Support Spending as % of Total BH $ • Latino Penetration by Provider • “Under 12” Initiative

23. Quality Management: Process CFT Process Measurement: “The Four Big Questions” • Has a trusting relationship been established with the family (engagement)? • Does the Child and Family know the family and has it identified the strengths needs and culture of the family? • Has an Individualized Service Plan been created that meets the needs of the child and family? • Is the team implementing, monitoring and modifying the service plan toward a successful outcome for the child and family?

24. Fall 2005 Reviews Region A – 67.8% Region B – 64.1% Region C – 74.1% Region D – 66.3% Region E – 73.3% Region F – 41.7% Statewide: 53.25% [n = 486] Winter 2006 Reviews Region A – 70% Region B – 64% Region C – 71% Region D – 61% Region E – 81% Region F – 53% Statewide: 60.45% [n = 418] Quality Management: ProcessCFT Process Measurement

25. Figure One Group Comparisons. Figure One shows a comparison of the average wraparound fidelity index (WFI) scores for the two groups at 6 months and the average baseline scores for five of the outcome measures at intake. The second row shows the difference in the overall average WFI scores for the two groups. The WFI eight point scale has been converted to a 100 point scale for ease of comparison. Rows three through seven show the intake data for four of the primary child and one primary family outcomes. These data reflect the six months prior to initiation of the wraparound process.From Rast, O’Day & Rider (2004) Improved Process Contributes to Improved Outcomes Wraparound Maine Symposium - Frank Rider

26. Wraparound Maine Symposium - Frank Rider Figure Two CAFAS and CBCL Scores. The graph on the left of figure two shows the average Child and Adolescent Functional Assessment Scale (CAFAS) Scores at intake and at six and twelve month intervals following intake. The open circles are the average scores for all 42 children, the black diamonds show the average for the 21 children receiving low fidelity wraparound and the grey squares show the data for the 21 children receiving high fidelity wraparound. The graph on the right shows the same data for the Child Behavior Checklist (CBCL) scores. From Rast, O’Day & Rider (2004)

27. Wraparound Maine Symposium - Frank Rider Figure Three Residential Outcomes. Figure Three shows a comparison of the impact of the fidelity of the Child and Family Team process on the restrictiveness of residential placement (left graph) and on the stability of placement (right graph). The figure on the left shows the average level of residential placement on a six level version of the ROLES. The open circles show the average for all 42 of the children, the black diamonds the 21 with low fidelity wraparound and the grey squares the 21 with high fidelity wraparound. The graph on the right shows the average number of residential moves for each group using the same symbols. From Rast, O’Day & Rider (2004)

28. Wraparound Maine Symposium - Frank Rider Figure Four Family Resource Scale. Figure Four shows the scores for the Family Resource Scale which measures a caregiver’s report on the adequacy of a variety of resources needed to meet the needs of the family as a whole, as well as the needs of individual family members. Higher ratings demonstrate more adequate resources. The graph on the left shows the average rating for the caregivers for all 42 children. The graph on the right shows the average rating for each group. The gray squares are for the caregivers with the high fidelity wraparound and the open circles are for the care givers with low fidelity wraparound. From Rast, O’Day & Rider (2004)

29. Comparing Outcomes for Arizona Children with and without Child and Family Teams: Ages 5-11From ADHS (01/08) at http://www.azdhs.gov/bhs/measures/charts_0108.pdffor all enrolled children in this age range Wraparound Maine Symposium - Frank Rider

30. Comparing Outcomes for Arizona Children with and without Child and Family Teams: Ages 12-17From ADHS (01-08) at http://www.azdhs.gov/bhs/measures/charts_0108.pdffor all enrolled youth in this age range Wraparound Maine Symposium - Frank Rider

31. “Wraparound” Works “Building on family strengths is essential if we are to prevent and control juvenile delinquency behavior. The Wraparound Process that embraces this concept can help prevent families from becoming abuse, neglect and delinquency statistics. It works well as an intervention model even for the most severe cases of abuse, neglect or delinquency.” Hon. David C. Bonfiglio, Superior Court Judge, 6/01 Testimony before Indiana Select Legislative Committee on Education

32. Adequacy and flexibility of case management (care coordination/wraparound facilitation) resources, • Adequacy and availability of direct supports and rehabilitative services as a significant enhancement to traditional clinical services, and • Continuing attention to maintain and improve observed, measured fidelity of wraparound (Child and Family Teams) process. “Second Generation” Tasks in Arizona (July 2007)

33. Arizona/JK Initiative - www.azdhs.gov/bhs Frank Rider – frider@ffcmh.org "The slowness of change is always respectable in the eyes of those who are in charge. It is a different story for the ones who are in pain.” Jonathan Kozol (1967), Death at an Early Age. Wraparound Maine Symposium – April 10, 2008 For MORE INFORMATION: