County of Humboldt Department of Health and Human Services Evidence Based Practice (EBP) Systems Change To Insure Success Rose Jenkins Conference October 3 – 4, 2006
With the help of the California Institute for Mental Health, the interrelated and dynamic processesthat link these program support divisions have been designed and piloted.These processes are a unique approach in terms of our organizational transformational work. They represent Humboldt County’s developmental efforts towards the identification of interrelated systematic government sector “Rapid Cycle” processes required to initiate service transformation (e.g., EBP’s).
Current MHSA Related EvidencedBased Practices Launched: • Multidimensional Treatment Foster Care (MTFC): A foster care placement and after care program for youth ages 12-18, chronic juvenile offenders extending 6 months for placement and up to 12 months after care services. • Incredible Years (IY): Parenting treatment and prevention program for parents with children ages 2-12 who exhibit conduct or behavior problems. • Functional Family Therapy (FFT): Family treatment for youth ages 11-18 who are at risk and/or presenting with delinquency violence, substance abuse, conduct behavior problems and family conflict. • Aggression Replacement Therapy (ART): For adolescent youth who show or are at risk of aggressive behavior.
Current MHSA Related Evidenced Based Practices Launched (cont’d): • Family to Family:Developing family resources and Team Decision Making models for families whose children are in or at risk of out-of-home placement. • Parent Child Interaction Therapy (PCIT): Intensive treatment designed to work with parents and children together and teach parents skills necessary to manage their children’s behavioral problems ages 2-7. • CalMap:Medication algorithm-based clinical decision making tool to assist physicians in treatment of schizophrenia and schizoaffective disorder. Roadmap to recovery education program for clients. • Project Impacts:Project examining physician attitudes toward medication algorithms with specific attention to computer assisted algorithm implementation and its effect on physician adherence to major depression recommendations.
Questions & Answers • What is Starship? • Starship is Humboldt County’s DHHS “nickname” for a governmental “Rapid Cycle” Change Management process prototype. • What is a “Rapid Cycle” process? • A Rapid Cycle process is a structured method to efficiently implement changes in an organization. • While there are several private sector models, Starship was developed with the California Institute for Mental Health to manage change in a governmental environment (i.e., DHHS).
Questions & Answers, continued • What is the basic function of each structure? • The functions vary depending on the project and stage of the process but can generally be defined as: • Administrative/Stakeholder function(s) • To identify an issue or program (new or existing) that should be studied. • To activate the Starship program support units. • To approve final recommendations and assure “Mothership” resources (e.g., IT/Financial Services/Employee Services/QI/Office of Client and Cultural Diversity) and Branch support and linkage are provided.
Research and Evaluation Unit Function(s) • To provide data on an identified issue or program in concert with Branches. • To provide literature reviews on Evidence Based Practices/information to Administration and Stakeholders. • To recommend and develop data and outcome approaches in conjunction with IT, Branches and needed Starship units. • To provide formative and summative outcome data to Administration, Stakeholders and Branches.
Training & Education Unit Function(s) • To provide or contract for pre-launch training and education to Branches and Stakeholders. • To provide or coordinate post-launch or ongoing training and education needs.
Integrated Services UnitFunction(s) • To provide assistance to Branch project lead(s) and assure linkage when technical assistance occurs. • To assure Starship units and Branches interact efficiently in the Rapid Cycle process needed to achieve the current objectives of an issue/program undergoing change. • To link with Branches and “Mothership” supportive services to assure program maintenance is provided.
AB 1259 (introduced by Assemblywoman Virginia Strom-Martin) = an integrated and comprehensive County health and human services system. AB 1881 (authored by Assemblywoman Patti Berg in 2004), authorized continuation of Humboldt County’s transformation work. AB 1881 goals, values and outcome expectations have guided Humboldt County in the development of its integrated system since 1999. The Mental Health Services Act and Welfare Redesign initiatives have helped to broaden and focus these efforts. Macro to Micro or “what we’re doing and why we’re doing it”
Macro to Micro(continued) • The fundamental concept underlying all of our change efforts has been that high quality, early, community and strength based intervention strategies result in the best long term outcomes for our clients. • The following goals and outcomes were embedded in AB 1259 and 1881 and reflected the priorities of DHHS Administration, Branch Management as well as the Mental Health Services Act and Welfare Redesign.
Specifically the Department, through its integrated program development and integration process, has and continues to be focused on: • Increasing alcohol and drug services to the “working poor”. • Co-occurring disorder intervention strategies where and when appropriate. • Integration of all program planning processes. • Recovery, resiliency, harm reduction and wellness oriented programming. • Evidence Based Practice and Practice Based Evidence initiatives that are measurable and outcome based. • The development of a foster care “continuum of care”. • Acknowledging and enhancing Transition Age Youth voice and role aimed at increasing their self sufficiency.
Focus(continued) • Differential response. • Ensuring that all children in our health and human service system receive mental health and health screenings. • Keeping all minors in County. • Improving access for services throughout County wherever clients live. Development of mobile service system. • Promoting integrated and multi-disciplinary oriented programming wherever possible and indicated. • Services being culturally relevant and reflective of diversity competence.
Focus(continued) • Strengthening the relationship between DHHS Branches and community service providers. • Prevention and early intervention. • Reducing the number of children removed from home due to safety/neglect issues. • Reducing repeat foster care placements and the maltreatment of children while out of home. • Shortening the amount of time to permanency. • Keeping families and/or sibling groups intact. • Increasing professionalism of our work force. • Quality Improvement and data collection focused.
Transition Steps • Development of the organizational structure necessary to transform the system. CIMH for technical assistance on • Administrative restructuring • EBP/Lit Search • Cultural Competence
Identified Primary Functions • Implementation Planning • Research & Evaluation • Training, Education & Supervision • Resource Development
Developed Guides and Reporting Structures for Implementation • What is the implementation process and structure? • Who needs to be involved in the implementation process? • What is the reporting process, who needs to be in the loop? • How will this be a transparent reporting process?
Implementation Guide • Designed to support planning • Planning completed by inter-agency/intra-agency implementation team • Shared implementation process
Implementation Team Members • Integrated Services Program Manager • Program Lead • Referral Source—Designated Manager • Fiscal • Research & Evaluation Staff • Information Systems Staff • Training Coordinator • Facilities & Equipment Staff • Quality Assurance Staff • Office of Client & Cultural Diversity • Employee Services • Community, family, youth, consumer partners
Integrated Services Manager • Facilitate and oversee implementation process • Partner with assigned Program Lead to meet and develop action plan for implementation • Provide transparent reporting to governing body
Implementation Team • Identify program lead • Identify how it fits in the organization • Embed in everyday business
Designated Referral Source • Manage and monitor referraldevelop internal structures and policy • Identify target population within the organizational structure for the practice • Partners with the practice provider to make sure referrals are made to the practice • Develop engagement strategies to follow-up with potential referrals.
Fiscal • Develop funding strategies • Develop monitoring process • Assist with budget (cost/revenue analysis) • Identify sustainability • Monitor following implementation
Research & Evaluation • Conduct needs assessment • Review/summarize literature • Establish fidelity & outcome measures • Produce audience specific reports
Other Key Systems/Roles • Information Systems • Training • Facilities & Equipment • Quality Assurance
Implementation Process • New Program Description • Target Population Identified • Fiscal • Staff Selection • Training & Clinical Supervision • Fidelity & Outcome Measures • Facilities & Equipment • Information Systems • Quality Assurance
Developed Two ReportingDocuments & Reporting Structure • Evidence Based Practice New Program Report • Rapid Cycle (EBP) Program Update Summary Report • Reporting StructureMonthly written reports to governing body
Training, Education and Supervision • Established a DHHS Branch Tri-Chair Training Committee, serves in advisory capacity to the Training Education Supervision Unit • Requested that each Branch and DHHS add a training section to their website, IS to link them to each other • Tri-Chair Training Committee Chairs are sharing their training fliers with Branches and DHHS • Training Unit has developed a training calendar, identifying Branch sponsorship, updated each month in the newsletter • Hired Staff to provide training and clinical supervision
What is PCIT? PARENT CHILD INTERACTION THERAPY • Brief Therapy model • In vivo parent coaching focusing on development of specific parent competencies. • Emphasizes relationship enhancement and effective discipline for children with acting out behaviors that are at risk of maltreatment.
Outcomes • Increases parent and child mental health functioning through structured, intensive modeling of praise and consistent expectations for behavior. • Reduced referral rate to child welfare system. • Skills taught generalize to other children in family.
What has worked well: • High consumer satisfaction • Positive outcomes • Objectives of the treatment model meet vision of all branches of department
Challenges • Placement and construction of site • Research and evaluation component for outcome measurement. • Staffing patterns • Dedication of staff for training and initial implementation.
Resources • Parent Child Interaction Therapy (Hembree-Kigin & McNeil, Plenum Press 1995) • UC Davis PCIT training website (http://www.pcittraining.tv/) • Spending Smarter: A Funding Guide for Policymakers and Advocates to promote Social and Emotional Health and School Readiness – National Center for Children in Poverty (http://nccp.org/media/ss05_text.pdf)