Wraparound Blog

Your Voice Needed! How Do We Scale Up Wraparound Without Losing Its Soul?

October 24, 2022 | Eric Bruns

Thirty years ago last month, I entered graduate school on a quest. I had spent two years out of college working at a residential facility for youth. I was eager to find a career in which I could shape the policy environment for child and family services so that young people would never unnecessarily be removed from their homes and placed in such institutions.

The people working there were caring and skilled at what they did. But the teenagers they served wanted nothing more than to be home. And not just for a few hours as a reward for getting to “Level 4” on their star chart.

Their caregivers – parents, grandparents, uncles and aunts – wanted them back as well. But they had unmet needs of their own and needed help to be able to maintain them safely in their homes.

I found an opportunity to learn about better ways of working with youth and families from my mentor, John Burchard, Ph.D., at the University of Vermont. During my time in Burlington, I spent two internship years working at Northeastern Family Institute (NFI), home to one of the country’s first Wraparound programs. One year I was a care coordinator, the next I was a therapist.

Like most states, Vermont had a lot of children and teens who had been placed in psychiatric and residential facilities over the years. The state wanted to bring these young people back as well as divert youth from future placements.

Given that placement in those facilities could cost the state tens of thousands of dollars per month, it seemed like a no-brainer that “doing whatever it takes” via community-based Wraparound would be much cheaper. It made good business sense. And, if it was done with quality and maintained safety, it was the right thing to do for families.

How did Vermont and NFI organize Wraparound to “do whatever it takes”?

Our staffing ratios were six families per care coordinator. We also had flex funds – essentially a blank checkbook to pay for whatever was needed in the plan of care.

We could work whatever hours we needed to, and had access to a full-time psychiatrist to help with medication management for our youths. We rotated on the crisis beeper, but only once every two months to make it reasonable and avoid burnout. In group supervision, we shared crisis plans and important information so we could be helpful if we needed to respond to crisis.

We didn’t have too much paperwork. We had our contact log and plans of care and that was about it.

All this was possible because NFI received a bundled “per youth per month” rate for every family it served. Some families required thousands per month at first to address crises, as it paid for intensive in-home service and 20 hours per week of respite care from relatives. But others required only a few hundred per month, as needs were met. In the end, it all evened out and was far cheaper than facility-based care. Families were able to experience people doing “whatever it takes” and staff could just make that happen.

We had fun and felt fulfilled because those system and program conditions made it possible. NFI’s per family rate allowed them to invest in their staff’s career ladder as well as in things we did together to build camaraderie and morale.

We saw families who had previously been wrung out by “the system” succeed and grow hope. Some youth had setbacks, but many began to thrive as their needs were addressed.

Based on evaluations and stories from projects like NFI’s – and the Alaska Youth Initiative, Kaleidoscope in Chicago, and many others – Wraparound has evolved over the past 30 years from a radical idea to a well-researched and widespread best practice that is increasingly listed on national registries of evidence-based practices.

In the United States, Wraparound is now used by behavioral health, education, child welfare, and justice systems in nearly every state to coordinate care for over one hundred thousand youth and families.

Unfortunately, research has also documented many examples where Wraparound is failing. All too often, our Wraparound Evaluation and Research Team finds a lack of adherence to Wraparound principles and bad outcomes for children and families.

We recently did an evaluation of a Wraparound project where we found that only three of 40 youth enrolled in Wraparound that year transitioned positively, such as because they made adequate progress toward their needs. Yes, that is less than 8 percent.

What tends to happen in Wraparound initiatives with such poor outcomes? They do not look anything like the original vision for Wraparound.

Documentation requirements are overwhelming. Flex funds are not available. If they are, paying $100 to register for a camp or after school program can take 10 hours of work to request and approve.

Individualized plans don’t happen because care coordinators are employed by the same agency as therapists, rather than having access to a rich service array of options. Family and youth peer partners’ primary directorate is to generate billable hours.

Of course, I also get to travel across the country and see examples where Wraparound providers and family run organizations have found ways to keep Wraparound’s soul, programs with 80% positive transition rates. Often, it’s at the expense of their leaders’ own mental health, as they fight the quest of managed care to maximize revenue and minimize expenditures at all costs.

Meanwhile, we hear reports of fidelity Wraparound being hard; that its expectations are too high and unrealistic. But this is not Wraparound’s fault. The overlay of managed care and fee for service on Wraparound efforts is based on antiquated approaches to care.

Quality Wraparound is not hard. It simply diverges from decades old traditional mental health models and financing structures that worry more about productivity hours and paperwork than actual support and help.

All this has left many to wonder whether the adoption of Wraparound at large scale by public systems has led it to “lose its soul,” sacrificing its initial spirit of “doing whatever it takes” to help youth with complex needs live and thrive in their homes and communities.

I have been invited by New Zealand’s national Wraparound initiative to present at their “hui” – a Maori word for “big gathering.” In New Zealand, Wraparound has grown from under 100 youths to nearly 600 just in the past few years.

They asked me what I’d like to present on. I said I’d love to try to help assure that, as they grow, their Wraparound efforts don’t “lose their soul.”

Part of that presentation will certainly be lessons learned from our research. As many of you have probably read, we have documented research evidence that using a Care Management Entity (CME) approach to organize and fund Wraparound promotes better fidelity, family satisfaction, and outcomes.

This is because CMEs, when implemented well, use monthly per member rates instead of fee for service, and operate independently from other provider organizations. Both allow for more individualized and tailored care for families. If the rate is adequate, and the rules ideal, the Wraparound provider organization can keep the savings in out-of-home expenditures and invest in new services and supports, retention bonuses for staff, espresso machines and ping pong tables, and happy and fulfilled staff (as I once saw in a trip to Ascent’s offices in Monroe Louisiana).

But looking at financing and policy options is just one way to preserve Wraparound’s soul.

The survey has two main questions:

1. What have you seen that is causing Wraparound to “lose its soul”?
2. What do we have to do to “keep Wraparound’s soul”?

Knowing the people who subscribe to the NWI newsletter, I fully expect to get an amazing response. We will also be sure to feed back what we hear to everyone in a future newsletter.

Be well and keep doing great work,

Eric