Clinical Pathways Project

1. Clinical Pathways Project August 2002 Charles Fishman Shirley-Ann Chinnery

2. Overview • CPP Project Framework • Clinical theory and practice • Cases - therapy and preliminary outcomes • Tool - clinical “Loot Bag” • Conclusion - Creating a system of care for SED kids

3. Population - Counties Manukau • Total population = 250,000 • 26% of the total population = 0-14 years • The youth population (15-24 yrs) = a further 14% of the total population • Maori Tamariki = 26% of child population Pasifika children = 25% • Counties Manukau is rated educationally as a decile 10 area

4. NZ: Child Welfare Context • DCYFS/Mental Health interface one of the most stressed • Responds to approximately 30,000 new notifications annually • Increased rate of child deaths in last decade • Primarily focuses on investigation • Limited outcome research in child welfare

5. Organised Systems of Care

6. Clinical Pathways Project • Based on IST • Evidence base for IST • Creation of a coherent system of care • Unit of intervention: child and family: contemporary social context • Resource implications

7. Clinical Pathways Project (CPP) • Tests a clinical pathway: • More efficient treatment • Increased cost efficiency • Community based care • Consumer centered • Outcome driven • Culturally safe treatment

8. S.E.S. S.S.U. C.Y.F. K.F.C.M.H. TE KAUNIHERA MAORI(Maori Caucus) Turoro, (Client & Family), Whanau One representative from each sector on this Council. To collaborate with all inter-sectorial groups. To manage systemic processes allowing smooth transition of case subjects. To address processes of tikanga and cultural safety

9. Significance • Detailed clinical pathway for intersectorial treatment • Provides data to support intersectorial model of blended funding • Teachable model

10. Presenting Problems • Kids with suicidal behaviour/ideation • Substance abuse • Depression, Psychosis • Anti-social behaviour • Other mental health problems • Domestic/Family violence • Child abuse: neglect, physical, sexual and emotional

11. CPP Design (1) • Design: 20 CPP Cases & 20 Comparison Cases • Stratified matching based on: • Age • Ethnicity • Number of out of home placements

12. CPP Design (2) Outcome measures: 3 month, 6 month and 24 month follow-up assessments: DISC HoNosca C-GAS CDI Family Assessment Device Satisfaction Costs

13. CPP Referral Criteria • Active Child Welfare involvement • DSM IV diagnosis/active Mental Health involvement • Access and availability of and to family • Excluded current clients

14. Clinical Theory and Practice

15. Edgar Levinson, MD (Fallacy of Understanding) Theoretical basis - Paradigms: 1. Biological and Psychoanalytic: problem within the individual 2. Communication:problem with communication between two people 3. Organismic: problem in the organization of the system

16. Origins of IST Structural Family Therapy: • Families of the Slums, 1969, Minuchin, et al • Family Therapy Techniques, 1981, Minuchin, Fishman • Treating Troubled Adolescents, 1988, Fishman • Intensive Structural Therapy, 1993, Fishman

17. Circularity of Systems Broader Social Context Macro Family Micro

18. Theory of Change Congruence Positive Change

19. Tenets • Problem psychologically based • Crises transform system • Co-ordinated therapeutic context transforms system

20. Therapeutic Crisis Induction Crisis = A dangerous opportunity - Chinese definition

21. Therapy Segment - K.L. Case • 13 year old boy • Presenting problem: Inappropriate behaviour, Homicidal threats, Sexual abuse history, Expelled from 16 schools (no school in Auckland will accept), Aggressive sexualised behaviour • Placement: Mother, (has been placed in the past) • Family System: Mother, Estranged extended family • Therapeutic system: Family, Individual therapist - 2x/week, (Mother goes to same therapist 1x/week)

22. K.L. Structural Map M.H. Mo Extended Family Social KL Services

23. “Poster Child” - D.C. • Out of control behaviour at home and school • Letter from member of Parliament to treatment team • Biological mother moved out of the home • DCYFS involved for 2 years • Campbell Lodge involved for 2 years

24. D.C. Structural Map M.P. Mo Fa M.H. Social DC Services

25. Intervention • Intensive family therapy work, especially parental dyad - social services intervention - often placement • Co-ordination between agencies and family creates crisis

26. Protocol • Plan/Goal: • Coherent system • Testing to establish base line • Work with treatment facility: behavioural paradigm • Work with legal advocate • Intensive work with family and other resources • Psychiatric intervention - e.g.: meds • Involve mentor-basketball

27. Outcomes K.L. = Functioning Well D.C. = Functioning Well J.R. = Functioning Well H.B. = Functioning Improved - Family still actively in treatment S.S. = Functioning Improved - Family still in treatment K.S. = Not functioning well

28. “Loot Bag”Homeostatic Maintainer

29. Loot Bag - Homeostatic Maintainer (HM 1) “Clinical Torch” To operationalise: person, system or process that when the system is perturbed, activate to maintain the status-quo

30. Loot Bag - Homeostatic Maintainer (HM 2) For example: • Ask…what are the consequences of misbehaviour – who is the “softie”? • Process…is there conflict avoidance? Eg: - child runs away from school many times – no change - child refuses to go to school – no activation • What is the threshold to include consequences such as the law? • At the agency level…not holding co-workers accountable

31. HM Case Examples • Runaway adolescent girl • Delinquent adolescent boy • Girl in State Hospital - shunning case

32. HM Case Presentation 1 • 14 year old girl • Presenting problem: Ran away from home 15 times, Living with a grown man • Placement: Inpatient hospital • Family System: Mother, Stepfather, Bio- Father, Grandparents, Cousin • Therapeutic system: Family, Child psychiatrist, and Consultant

33. HM Case Presentation 2 • 17 year old boy • Presenting problem:Out of control behaviour • Placement: Inpatient hospital • Family System:Mother, Father, Grandmother • Therapeutic system: Family, Child psychiatrist, Social worker, Former therapist, and Best friend of boy

34. HM Case Presentation 3 • 14 Year Old Girl • Presenting problem: Running Away Continuously, Pregnant • Placement: In hospital - to be sent to state hospital • Family System: Mother, Stepfather, Older sister-16 • Therapeutic system: Family, Child psychiatrist, Social worker, and Former therapist

35. HM Case Presentation 3 (cont.) • Therapy:1. Organize the system • 2. Create a crisis - shunning • 3. System reorganization • Result: New structure - effective parental unit. Hospital works with girl - no State Hospital • 2 Year Follow-up: No more running away, Family reorganization

36. Development of a Coherent System of Care

37. Development of a Coherent System of Care (1) • A shared systems philosophy among stakeholders central to the care system • Commonly articulated care system goals • Family therapy expertise • Funding that supports collaboration, ie blended versus silo • Interagency participation and collaboration in formulation of service delivery goals

38. Development of a Coherent System of Care (2) • Intersectorial participation and contribution to policy formulation specific to the child welfare/mental health interface • Collaborative commitment to the inception and continuance of evidence-based practice • Data system to track performance

39. Haere Ra