Wraparound Blog Archives - Page 2 of 5 - National Wraparound Initiative (NWI)

New Research Study Sheds Light on Reliability, Validity, Potential Improvements, and Underlying Theory of the WFI-EZ

July 25, 2023 | NWI

By Jonathan Olson and Eric Bruns

University of Washington Wraparound Evaluation and Research Team and National Wraparound Implementation Center

Research consistently shows Wraparound care coordination promotes better residential, school, and mental health outcomes for youth with complex needs than services as usual (Olson et al., 2021). However, as we frequently discuss on blog posts, reports, and other transmissions from the National Wraparound Initiative (NWI), high-quality, model-adherent Wraparound service delivery is critical to assuring Wraparound provides this boost to child and family-serving systems “as usual.”

To help assure Wraparound quality and fidelity, the University of Washington Wraparound Evaluation and Research Team (UW WERT) has provided access to the Wraparound Fidelity Index, Short Version (WFI-EZ) for over 10 years. The WFI-EZ and other measures of the Wraparound Fidelity Assessment System (WFAS) aim to help Wraparound Provider Organizations (WPOs) assess the degree to which the core components of Wraparound are actually being used in practice. Over the past decade, more than 15,000 caregivers, care coordinators, youth, and Wraparound team members have completed a WFI-EZ survey.

Despite its widespread use, however, a published study of the psychometrics, reliability, and validity of the WFI-EZ has not previously been available – until now.

The Journal of Child and Family Studies (Bruns, Olson, Parigoris, Parker, & Walker, 2023) has published a new study examining the psychometrics of the WFI-EZ. The study had three aims:

1. First, to determine if the underlying factor structure of the WFI-EZ actually aligns with the underlying structure that UW WERT has used to summarize WFI-EZ results; that is, the four key elements of the practice model promoted by the National Wraparound implementation Center (NWIC), plus a fifth focused on being data-informed.
2. Second, to assess the reliability of the measure via internal consistency, agreement across caregiver and care coordinator versions of the measure, and a small test-retest reliability study.
3. Finally, we assessed validity by comparing WFI-EZ scores for groups that should differ, such as WPOs with higher versus lower Wraparound climate or systems with and without training and coaching.

In the following paragraphs, we provide a brief overview of findings and their implications. For additional details, readers can also read a copy of the full paper as published in JCFS.

Methods

The WFI-EZ is a brief self-report survey, with versions for parents/caregivers, care coordinators, youth, and team members. All versions include a Section A with four items that assess fundamental elements of Wraparound practice: Presence of a team, a plan of care, regular meetings, and decisions driven by families. In addition, all respondents complete 25 items (Section B) that assess Wraparound fidelity. These items are organized into 5 subscales that correspond to the NWIC practice model: effective teamwork, natural supports, needs-based, strengths-driven, and data and outcomes-based.

Caregivers and youth complete four additional questions (Section C) that assess satisfaction with the Wraparound process. Finally, the caregiver and care coordinator forms include 9 items (Section D) that assess outcomes such as caregiver strain and resilience, and youth residential, school, and justice outcomes.

Study Methods

UW WERT analyzed data from 10,955 caregivers and 6,088 care coordinators within 243 WPOs in 25 states that were entered into WrapStat (the web-based data entry and management system for WFAS measures) and its predecessor, WrapTrack. Data collected between 2011-2021 were analyzed for this study.

In addition, 26 caregivers and care coordinators completed the WFI-EZ twice over two weeks to assess test-retest reliability. Finally, we used program-level data from 15 WPOs in one state to assess “known groups validity.”

Analyses included exploratory factor analysis (EFA) and paired-sample and independent-sample t-tests, as well as calculation of intraclass correlations (ICCs) and Pearson’s (r) correlations.

Results

WFI-EZ reliability and validity

As summarized below, results supported the reliability and validity of the WFI-EZ. However, analyses revealed some opportunities for improvement.

• The total WFI-EZ index showed excellent internal consistency (alpha = .92), meaning that its items are well-related to an underlying construct (i.e., Wraparound fidelity). The original five subscales showed borderline to high (.54 to .84) internal consistency, indicating these subscales also generally can be used reliably, with some potential room for improvement.
• Test-retest data showed excellent two-week agreement for caregivers (.92). However, reliability was only acceptable for care coordinators (.74).
• Results of validity tests indicated that average WFI-EZ scores were significantly higher for groups that would be expected to be higher. For example, total WFI-EZ fidelity was significantly higher for youth who received services that met the basic definition of Wraparound (as assessed by Section A). Caregivers with higher satisfaction with their care and their progress (Section C) also showed significantly higher average fidelity ratings. Finally, caregivers who received services from WPOs with higher organizational readiness to implement Wraparound reported significantly higher average fidelity scores on the WFI-EZ.

Factor Structure of the WFI-EZ

Results from our EFA revealed four factors rather than five. Moreover, these factors did not completely align with the original subscales of the WFI-EZ, defined as per the NWIC model.

• Although factors tapping into planning, teamwork, and natural supports were found, a fourth factor emerged that comprised 10 items from across the original five factors that seemed to relate to intermediate outcomes of Wraparound, including enhanced family assets and effective services and supports.
• While some of these items were from the original Outcomes-Based subscale (e.g., “Wraparound has given me confidence as a caregiver”), others came from the Natural Supports (e.g., “Wraparound has helped us get more support from friends and family”) and Needs-Based (e.g., “Wraparound connected my family to community supports I found valuable”) subscales.
• The internal consistency (reliability) of the new, empirically-derived subscales showed better internal consistency, test-retest reliability, and cross-informant agreement than the original subscales.
• Finally, some WFI-EZ items did not load on any of the empirically-derived factors, and had low item-total correlations. These items could thus be characterized as not adding value to the WFI-EZ overall.

Implications for Wraparound Evaluation and Practice

Together, the findings of this study provide evidence that the WFI-EZ is a reliable and valid measure of Wraparound implementation and fidelity. As described above, the total index and the original theoretically-derived subscales show acceptable levels of internal consistency and test-retest reliability. The measure also results in higher average scores for groups as would be expected – e.g., WPOs with stronger organizational readiness and caregivers who reported experiencing better satisfaction with their family’s progress.

However, results suggest that there is also room to refine the WFI-EZ to make a good measure even better. Other study results help provide guidance for how best to use the WFI-EZ – for research, evaluation, and quality improvement.

Alternative ways of reporting WFI-EZ results

The current five domains of the WFI-EZ align with the practice model on which our NWIC colleagues train and coach. We were pleased to find that these subscales were adequately reliable and valid, and to be largely reflected in the results of the exploratory factor analysis.

• At the same time, however, the subscales that were found via the EFA provide an intriguing alternative structure for WFI-EZ data that aligns with longstanding Wraparound theories of change. Walker and Matarese (2011) theorized that effective teamwork is critical to managing a planning process that results in intermediate outcomes such as enhanced natural supports, increased family assets and more effective services and supports. This aligns well with an alternative way of organizing WFI-EZ data that emerged from the EFA, which found factors related to planning, teamwork, natural supports, and intermediate outcomes. Taking this idea further, items from the proposed “Intermediate outcomes” domain can be further broken down into enhanced family assets and effective services and supports.
• All these factors are assessed by the WFI-EZ, and all are proposed to lead to long-term outcomes for Wraparound-enrolled youth and families that are also assessed by the satisfaction and outcomes sections (C and D) of the WFI-EZ.
• Thus, the current study reveals an intriguing alternative way of summarizing results. The figure below shows a way in which these study-derived factors may be organized. This framework may be explored in future research by UW WERT or others, and/or used by WFI-EZ collaborators to summarize their process and outcomes with data.

Figure 1. Theory for implementation and effectiveness of Wraparound as assessed by items and domains of the Wraparound Fidelity Index, Short Form (WFI-EZ)

Click image to enlarge

Guiding evaluation planning

Among many other actionable findings, the study revealed that WFI-EZ data from care coordinators may be less reliable than for caregivers. This discrepancy is perhaps not surprising, given that parents and caregivers are immersed in only one Wraparound episode – their own – while care coordinators support many families over months and years, potentially reducing their recall – and thus, the reliability of their assessments. UW WERT typically recommends that, when faced with limited resources, Wraparound initiatives and WPOs prioritize data collection from caregivers, to assure their voice. These results provide another, data-informed, rationale for prioritizing caregiver report.

Revising the WFI-EZ to reduce burden and increase reliability

As described above, four WFI-EZ items did not load on the new factor structure. Removal of these particular items also resulted in better internal consistency of the overall measure. Other items were found to contribute little variance above and beyond other items, and thus may be considered duplicative. Thus, UW WERT is considering a possible revision to the WFI-EZ to increase reliability, which would have an added benefit of shortening the tool and reducing respondent burden.

Conclusion

Until such revisions are made, however, users of the WFI-EZ can be confident that the current version of the tool is a psychometrically sound measure of Wraparound fidelity and implementation, and that subscales presented in reports generated from WrapStat summarize the data in ways that are reliable and valid. UW WERT looks forward to continuing to analyze data from the many hundreds of WPOs that license the WFI-EZ and other measures of the WFAS.

We will continue to report back results, refine our measures, and use the data to better understand implementation and outcomes of Wraparound. It is only by helping you achieve your mission on behalf of youth and families that we can achieve ours.

Nationwide Data Insights from WrapStat

June 14, 2023 | NWI

WrapStat data can show us how sites differ in terms of types of youth and families enrolled, length of enrollment, level of fidelity and satisfaction, rate of progress, and reasons for discharge. By putting all these data together, we can learn what factors might be associated with fidelity and outcomes.

We invite you to check out the accompanying infographic that summarizes what we learned. As you can see, there were some interesting findings:

• WrapStat collaborators have been making new entries into their youth rosters steadily since WrapStat’s launch in 2020 – approximately 4,000 youth in 2020, 7,000 in 2021, and 5,000 in 2022.
• The median age of youth entered into WrapStat is 15. Over 60% of youth entered into WrapStat were ages 11-17 at time of enrollment.
• Of the 6,418 youth with race data included, 53% identify as White. Eighteen percent identify as Black, 12% Latinx, 7% Mixed race, 3% Native American/Alaska Native, and 1% Asian. Seven percent identify as belonging to another racial/ethnic group or preferred not to say.
• Critically important, WFAS collaborators are not consistently entering demographic data such as race into WrapStat. Two thirds of entries are missing race and ethnicity data and over half do not include the gender of the youth. Such a pattern compromises our ability to learn about whether, for example, racial differences in fidelity, satisfaction, or outcomes may exist in Wraparound systems of care.
• Similarly, only half of youth rostered in WrapStat have a discharge date, and of those, only 60% have a reason for discharge entered into the system. This means that, as of now, despite having nearly 19,000 youth entered into WrapStat, we only have discharge data for about 30%.
• On the positive side, our initial analysis illuminates just how much data we now have on domains such as caregiver- and youth-reported fidelity and satisfaction, and Wraparound team membership and processes. From 2020-2022, 9,715 WFI-EZ and TOM 2.0 forms were entered into WrapStat, with 2022 being the greatest year for data collection.

UW WERT and NWI will continue feeding data back to our national Wraparound community of practice. We will examine trends in Wraparound implementation nationally, and identify ways licensed users can contribute to the collective quest to use data to continually improve Wraparound – locally and globally.

New Animated Video for Families Helps Wraparound Data Collection in West Virginia

May 21, 2023 | Eric Bruns

Youth with complex needs and their families depend on systems, organizations, and practitioners to provide timely, engaging, high-quality services. As such, measuring timeliness, engagement, fidelity – and most importantly, outcomes – is critical to making sure systems, programs, and practitioners are actually delivering effective care.

However, we also know that collecting data on these things is difficult. Getting input from youth and caregivers is particularly challenging given all the demands on their time.

In West Virginia, the statewide Wraparound initiative is committed to collecting – and using – data on outcomes, fidelity, and provider and system readiness. As part of this effort, West Virginia has an impressive effort underway to collect youth, caregiver, and practitioner data using the Wraparound Fidelity Index, Short Form (WFI-EZ).

Hubbed at the statewide Center of Excellence for Recovery at Marshall University, West Virginia uses the WrapStat system from University of Washington Wraparound Evaluation and Research Team to systematically maintain a roster of all Wraparound-enrolled youth across nearly 30 providers and multiple funding streams. Marshall then uses WrapStat’s automated systems – plus a clear plan and hard work – to get WFI-EZ data with a good response rate that assures the data is reliable, valid, and useful to meet their information needs.

The evaluation team just unveiled a new component of their statewide Wraparound evaluation plan. Lydia Shaw, M.S., TCOM and Wraparound Fidelity Coordinator at the Center of Excellence used the online program Vyond to create a 2-minute video, which explains the WFI-EZ survey process for caregivers and staff in clear, accessible language, complete with animations.

As described by Ms. Shaw, “we at Marshall University wanted to make sure to explain the WFI-EZ in a way that was easily understood by all who complete surveys in WV. We have used Vyond in the past as a means to create bite sized animated informational videos and decided this would be a great route to go for our WV Families.”

According to Lydia and her colleagues, after they created the video, it wasshared with Care Coordinators and added to the Family Instructions Forms that are shared with families randomly sampled to receive surveys. When necessary, Care Coordinators also show the video to selected families to help them complete the Caregiver WFI-EZ forms.

Lydia and the team in West Virginia encourage others to use their video as inspiration. We hope other states will share their own innovative methods to encourage data collection and use with us at the NWI and UW WERT as well!

Beyond Psychotherapy and Medication: Wellness, Wellbeing and Fun Interventions

April 20, 2023 | Janet Walker

A new research review from Pathways RTC has information with important implications and reminders for young people, families and providers involved in Wraparound. The review is entitled Beyond Psychotherapy and Medication: Wellness, Wellbeing and Fun Interventions Should be Part of Robust Systems of Care for Youth and Young Adults.

The title captures the general argument of the review, which covers key portions of the vast research literature that demonstrates positive impacts on mental health from interventions that directly promote wellness, wellbeing and fun. The review highlights findings showing mental health impacts among young people experiencing anxiety, depression and other mental health conditions. These interventions run the gamut from aerobic exercise, resistance training, dance, hiking and surfing; to yoga, meditation, mindfulness, deep breathing and participation in music and the arts. There is also promising evidence from a systematic review of “behavioral activation” interventions, which promote participation in pleasurable activities generally.

Some of the studies covered in the review included qualitative findings showing that youth and young adults had strong preferences for these kinds of interventions as compared with traditional mental health therapies or medication.

Just to be clear, these activities are not add-ons to more traditional mental health interventions, they are mental health interventions. In many cases, these interventions had similar or even greater positive effects than mental health treatments like psychotherapy and medication. What is more, these are interventions that can be delivered by “lay” providers or peers, which is an advantage given the current acute shortage of mental health providers.

When implemented well, Wraparound provides a mandate and the resources to support youth and family participation in community-based recreational and social activity. And yet, as compared to the effort expended on organizing more traditional forms of therapy, only a relatively tiny proportion of a Wraparound team’s time and attention is typically focused on promoting engagement in recreation or the arts, or activities focused on wellness, wellbeing or fun. Plans that do address recreational or social needs often have what appear to be perfunctory, off-the-shelf goals and strategies, like purchasing a family gym membership or providing vouchers for movie tickets.

What if, instead, Wraparound teams devoted more significant amounts of time, effort and creativity to planning for ongoing involvement in community-based activities that young people and families look forward to, and that deliver wellbeing and joy? The principles of Wraparound certainly support this, and it is clear from research that it would contribute meaningfully to more positive outcomes for youth and families.

Wraparound and FFPSA… One Year Later

March 10, 2023 | NWI

It is hard to believe it has been over a year since “Intensive Care Coordination Using a High Fidelity Wraparound Process” (i.e., Wraparound or High Fidelity Wraparound ) was added to the inventory of research supported programs by the Title IV-E Prevention Services Clearinghouse. This made Wraparound eligible for Title IV-E reimbursement under the Family First Prevention Service Act (FFPSA).

Since this announcement, the trainers, consultants, and evaluators working under the auspices of the National Wraparound Initiative, National Wraparound Implementation Center, and the newly relocated Innovations Institute at the University of Connecticut, have been increasingly fielding requests from states and Wraparound provider organizations for help. States who included Wraparound in their FFPSA five year plans are now realizing that meeting federal expectations for evaluation and continual quality assurance may need to be more stringent and specific than expected.

As detailed in our guidance document on how to meet FFPSA evaluation and CQI requirements, state or local evaluations of Wraparound do not need to meet criteria for a rigorous experiment (e.g., random assignment or comparable comparison group). However, evaluation plans do need to be capable of providing meaningful information that can help keep the state and/or local providers on track, in areas such as:

1. Population of focus: Are youth and families being served consistent with the goals for the program?
2. Implementation: Are necessary system and program supports that ensure successful implementation and outcomes (e.g., staffing ratios, timely engagement, workforce training) in place?
3. Is adequate quality and fidelity of Wraparound being achieved?
4. Are families experiencing positive outcomes? Are youth “at home, in school, and out of trouble”? Are core child welfare outcomes of safety, stability, and permanency being promoted?

The Wraparound Evaluation and Research team at University of Washington has been thrilled to provide support to several state roll-outs under FFPSA. Similarly, NWIC is aiding states to develop strategic plans that will result in hospitable system and provider contexts for Wraparound, and offering technical assistance and training for the workforce.

If your state has included Wraparound in its FFPSA plan (or is planning to do so), here are a few resources and things to remember with respect to evaluation and implementation:

1. Convene state-wide (and local) oversight groups as early as possible that include relevant partners in the effort (leaders from all relevant systems, provider organizations, family and youth leaders, community organizations). This group should collectively design the state strategy and evaluation plan, review data, and make mid-course corrections.
2. Consult tip sheets from the Administration for Children and Families and our own NWI guidance for basic ideas.
3. To aid in fidelity, satisfaction, and outcomes monitoring, UW WERT’s new WrapStat system and measures of the Wraparound Fidelity Assessment System are well validated and helpful in staying on track.
4. Do not hesitate to reach out for help! NWIC and UW WERT are always here to provide assistance on system design, workforce development, and evaluation.

Tribute to Richard Donner

February 24, 2023 | NWI

With the recent death of Richard Donner, we lost a good friend and respected colleague whose vision and commitment were instrumental in building the family movement within children’s mental health. Richard was unwavering in his vision for making family voice and choice a reality.

In the early 1980s – before Wraparound was defined with “family and youth voice and choice” as its first principle, and before “family driven” was an aspiration for systems of care – Richard was a therapist and social worker with a deep commitment to partnering with families. His approach was based on building trust, and showing deep respect for the expertise and perspective that families brought to the table. At the time, this was a radical idea that ran directly counter to mainstream practices in children’s mental health services and systems.

Working in Kansas, Richard became part of the family movement that emerged in the 1980s and grew steadily for decades, eventually inspiring and collaborating with a parallel movement demanding youth and young adult voice in mental healthcare. Richard’s role in the family movement is exemplified by his steadfast support for the development of the Kansas organization, Keys for Networking, and the formation of the National Federation of Families for Children’s Mental Health. Richard was a key figure in early work developing Wraparound, as well as the kinds of supports that families and young people wanted once their voices were empowered, such as respite, peer support and mentoring. He was a voice for change for children, youth and families, helping to make it possible for more young people to live and thrive in their home communities.

— Janet Walker, Eric Bruns and Jane Adams

Update on SMART-Wrap: A Text-Based Fidelity and Outcomes Monitoring for Wraparound

December 10, 2022 | Eric Bruns

Earlier this year, we reported that the University of Washington Wraparound Evaluation and Research Team (UW WERT) and 3C Institute received funding from the National Institute of Mental Health (NIMH) to develop and test a “mobile Routine Outcomes Monitoring” (mROM) system for Wraparound that collects data from parents, caregivers, and youth using text-based surveys.

SMART-Wrap (Short Message Assisted Responsive Treatment for Wraparound), aims to provide a low-burden, reliable approach for obtaining feedback from caregivers and youth enrolled in Wraparound. Data will be available to care coordinators, supervisors, and managers for use in monitoring fidelity, satisfaction, and outcomes for use in planning for individual families, supervision, and quality assurance for the entire Wraparound program. An initial phase of effort engaged over 70 experts from the National Wraparound Initiative (NWI) community on how the SMART-Wrap System would work, and to identify and develop wording for survey items.

Initial Results and Responses

Working with two Wraparound provider organizations – Region 6 Services of Nebraska and Lutheran Community Services Northwest of Washington State – we conducted an initial round of usability testing with 12 parents and caregivers and five youth served by six care coordinators. Results found that:

• Text messages with linkage to SMART-Wrap surveys were opened 86% of the time and surveys took an average of approx. 30 seconds for youth and caregivers to complete.
• Responses to user surveys were very positive:
  • Over 90% of caregiver and youth testers “agreed” or “strongly agreed” that the SMART-Wrap system was easy to use.
  • 100% of testers “strongly agreed” that they were “satisfied with the system” and 100% reported it did not take too much of their time.
• SMART-Wrap obtained a mean score of 82% on the System Usability Survey (SUS), a widely used measure of technology acceptability and usability. This far exceeds the 68% benchmark for usability established via research on the SUS.
• Focus groups with parents and youth provided critical feedback for improvement on:
  • SMART-Wrap items – parents said satisfaction and fidelity items should specify the time period for feedback, because care coordinator turnover may mean they had varying experiences over time.
  • Item wording – youth said to simplify items.
  • Response scales – youth suggested using emojis
  • Timing of sending surveys – Parents and youth both suggested the system should send texts at more convenient times
  • Setting up for success – Parents and youth both recommended care coordinators should help families set the system up in their phone as part of the engagement phase, to explain its purpose and make sure they recognize the sender.

Specific Quotes from Parents

• “I liked doing this. It was quick and easy.”
• “Sometimes I almost disregarded the texts because I wasn’t paying attention and almost mistook them for spam.”
• “It was simple and straight forward I didn’t have any issues at all.”
• “Just knowing that my team is there and if I need help or have question to issue, it helps having other people point of view.”
• “I think it could be a valuable resource if they decide to use it.”
• “To the point and fast to communicate”

Data collected showed reasonably good variability across the 11 SMART-Wrap engagement, satisfaction, fidelity, and outcomes items. See the table below for how responses looked by item for one user testing site.

Next Steps for the SMART-Wrap System and Opportunities to Get Involved

Development of Dashboard and Reporting System

A dashboard and reporting system are now being developed for Wraparound provider organizations that will present data in “real time” to care coordinators, supervisors, and managers, to help them respond to individual families who may be struggling and provide effective support to all families based on data.

Pilot Testing

UW WERT and NWI are now seeking additional SMART-Wrap pilot test sites for a second round of testing from February – June 2023. If you are interested in learning more about the SMART-Wrap system and/or being a pilot test site, we invite you to join us for a webinar on Tuesday January 17 at 2pm ET / 11am PT. 

On the webinar, we will provide an overview of the system and how it works, present initial results, and describe how results are informing improvements. We will then present details on how your Wraparound program or initiative can participate in a new round of testing, expectations of sites, and incentives for participants, and answer questions. In the meantime, you can also go to the website for UW WERT to find a summary for interested SMART-Wrap pilot sites.

Have Questions or Want to Be a SMART-Wrap Pilot Site?

To express interest in being a SMART-Wrap pilot site or ask questions, please feel free to contact us at wrapeval@uw.edu and/or ebruns@uw.edu.  

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

Join Our Team! An Opportunity for Researchers, Graduate Students, and Trainees to Help Grow the Research Base on Wraparound and Systems of Care

September 23, 2022 | NWI

If you follow news and updates from the National Wraparound Initiative, you know that the NWI’s driving purpose is to conduct research on “what works” for youth with complex needs and their families and then translate that knowledge into action in the real world for real youth and families.

Working with the National Wraparound Implementation Center (NWIC) and hundreds of partners across the country, our team at the University of Washington, Portland State University, and the University of Maryland, Baltimore, has conducted rigorous research, gotten federal research grants, developed evaluation and quality assurance measures, and synthesized research on the impact of Wraparound.

As a result, Wraparound is now widely understood to be a research-based practice. Moreover, states and organizations that implement Wraparound have access to a wealth of resources to help their efforts. These include implementation standards, training curricula, coaching tools, and measures of practice fidelity as well as organizational and state supports, just to name a few.

The volume of data being generated from all these measures and tools is immense. That is why we are issuing this call to researchers, students, and trainees to join us in our work.

If you are a graduate student seeking a thesis or dissertation topic, or are a researcher with expertise in child and family service delivery, and wish to take advantage of NWI and NWIC’s wealth of data and partnerships, we want to hear from you! Researchers, post-doctoral fellows, and graduate students who are interested in accessing, analyzing, and writing up or presenting results can reach out by emailing us at wrapeval@uw.edu.

In your email, tell us a little bit about yourself, your skills, and your research interests. Once we hear from you, we will provide you with a survey that will help us better understand whether and how we might provide you with access to relevant datasets, and how we might work together. To help you get started, see the table below to see examples of relevant research questions and datasets that qualified research partners might be able to use.

We hope to hear from you, so we can make the most of the incredible, data-informed movement that is Wraparound systems of care.

Eric Bruns,
Professor and Co-Director, NWI

Janet Walker,
Professor and Co-Director, NWI

Jonathan Olson,
Research Scientist, UW WERT

Kim Estep,
Director of Training, NWIC

New National Institute of Mental Health Grant Supports Development and Testing of Text-Based Outcomes Monitoring System for Wraparound

May 13, 2022 | Eric Bruns

Multiple research studies have documented the potential for positive effects of routine outcomes monitoring (ROM) in health care and behavioral health services.

Defined as “session-to-session measures of client progress to evaluate and improve treatment outcome,” ROM is also a core component of Wraparound care coordination as trained and supported by the National Wraparound Implementation Center (NWIC) and others.

At every Wraparound meeting, for example, the team should review and/or collect data on the family’s own rating of progress toward meeting their priority need(s) and vision for the future. Collecting such information can reinforce when recognizable progress is being made or highlight elements of a plan of care that need to be revised. ROM can improve the alliance among Wraparound team members, aid in supervision, and help a Wraparound provider organization be alerted when a youth, caregiver, or family is “off track” or experiencing an otherwise unknown crisis. Furthermore, when aggregated, such data can help identify provider organizations or other units that are achieving positive outcomes – or need attention to improve the quality of their care.

As described in this wonderful review by some of the world’s leading researchers on ROM, however, significant barriers impede actual implementation of ROM. Barriers include financial burdens, time burdens, competing stakeholder needs, and staff turnover, among many others.

In Wraparound, even though being “outcomes-based and data informed” may be our most important principle, our experience indicates consistent collection of progress and process data is rare. Fidelity data confirm this problem.

In an attempt to overcoming practical barriers to ROM in Wraparound, the University of Washington Wraparound Evaluation and Research Team (UW WERT) has partnered with 3C Institute on a recently awarded grant to develop and test a “mobile Routine Outcomes Monitoring” (mROM) system specific to Wraparound.

The proposed SMART-Wrap (Short Message Assisted Responsive Treatment for Wraparound) product will use brief prompts sent by text that can be read and responded to in a matter of seconds. Data would then be sent securely to a dashboard linked to UW WERT’s WrapStat system for review by the family’s care coordinator and others responsible for providing effective Wraparound support. If necessary, the system will send alerts to helpers, which could be when a family is in trouble or not making progress, or when progress and/or positive outcomes should be celebrated.

Given that 90% of text messages are opened within three seconds of their receipt, our hope is that “SMART-Wrap” may serve as a way to reduce the cost, time, and logistical barriers to getting actionable, “real-time” information from caregivers and youth to inform teamwork, plan of care revisions, supervision, and program evaluation.

Over the course of four phases of work, this project will:

1. Get input on SMART-Wrap system functionality from parents/caregivers, young people, Wraparound providers, mROM researchers, and other experts;
2. Develop an initial SMART-Wrap prototype;
3. Test out SMART-Wrap usability and feasibility with a small number of programs and enrolled families;
4. Prepare for a larger test of the system, incorporation into WrapStat, and dissemination to the field.

As some may remember, a survey of the National Wraparound Initiative community of practice in 2020 informed the original NIMH grant and demonstrated interest among Wraparound initiatives nationally. Now that it has been awarded, we plan to continue to inform and engage Wraparound experts nationally as we use NIMH funds to develop and test SMART-Wrap over the next 18 months.

If your Wraparound Provider Organization or initiative is interested in participating in this project in some way, please do not hesitate to contact UW WERT at wrapeval@uw.edu.

As always, we are grateful to be part of a national movement to provide effective care to youth with the most complex needs and their families. We hope this project will be yet another successful undertaking that advances Wraparound and its positive impact.