Wraparound Blog Archives - Page 3 of 5 - National Wraparound Initiative (NWI)

New Systematic Review Shows Wraparound to Be Effective, Particularly for Youth of Color

April 12, 2021 | Janet Walker

For nearly 30 years, “Wraparound” has been adopted in states and jurisdictions across the country to better meet the mental health and other needs of children and adolescents with serious emotional and behavioral needs and their families, and to keep them safely in their homes and communities. However, it has long been debated whether Wraparound is actually more effective than traditional services.

Journal of the American Academy of Child and Adolescent PsychiatryJournal of the American Academy of Child and Adolescent Psychiatry

A new research article, published in the Journal of the American Academy of Child and Adolescent Psychiatry and downloadable in full from the Journal’s website, finds that Wraparound does consistently produce more positive outcomes for these youth. Moreover, Wraparound may hold potential for reducing disparities in outcomes for youth of color, disparities that have long been found for mental health services.

Using a widely-used technique known as “meta-analysis,” a team led by Jonathan Olson, Ph.D., an NWI-affiliated Research Scientist at the University of Washington, examined the results of 17 controlled studies published between 1996 and 2019 that compared the effects of Wraparound to services as usual for similar youth with “serious emotional and behavioral disorders.”

The study found significant effects in favor of Wraparound across a range of important youth outcomes – including reduced out-of-home placements, improvements in mental health functioning, and better school attendance and achievement. The study also found significantly lower overall costs of care for youth in Wraparound, due to less spending on costly out-of-home placements. Across the 17 studies, Wraparound effects were more positive for samples with higher proportions of youth of color.

“For many years, public systems have used Wraparound because it makes sense and provides families with the kind of compassionate approach they say they want and need,” said Eric Bruns, Professor of Psychiatry and senior author on the research team. “Now we have clear evidence that Wraparound is also more effective and cost-effective than traditional services.”

Wraparound was innovated in the 1980s as an alternative to service delivery strategies that were driven by professionals and forced families to navigate complex systems and services on their own. When families became overwhelmed and/or failed to get their needs met, costly institution-based care was often the result.

Instead, Wraparound invests in a care coordinator with low caseloads who convenes a team that includes the family’s friends and natural supports, as well as professionals. “Wraparound lives up to principles we want to uphold – for example, being youth- and family-driven, strengths-based, and using a team of people with a blank checkbook to ‘do whatever it takes’ to meet the needs of the youth and family,” said Bruns. “While many states have taken Wraparound to scale, others have been more hesitant, saying it wasn’t ‘evidence-based.’ This study should help address those concerns.”

Olson points out, however, that the study also reinforced how important it is to implement Wraparound with quality, and in a way that is true to the model.

“Unfortunately, many studies were conducted before there were measures of fidelity, or measures of ‘doing Wraparound right,'” said Olson. “However, for studies that did measure fidelity, we saw more positive outcomes for youth and families who received care that was of high-quality and closely adhered to Wraparound principles.”

Bruns said that the finding related to the potential for Wraparound to better meet the needs of youth of color was unexpected, but perhaps not surprising.

“We need to remember that in all these studies, Wraparound was compared to more traditional mental health, child welfare, and juvenile justice services,” Bruns said. “And there is a long history of research showing disparities in access and outcomes for youth of color and their families in such systems. It may be that by allowing for more youth and family voice and choice, and teams that include family, friends, and community members, Wraparound helps reduce those disparities.”

Bruns emphasized, however, that such questions were not an explicit focus of the new meta-analysis, or of the studies that were reviewed. “In Wraparound and youth services in general, we need to continue to research what may address racial and other disparities in outcomes with greater rigor.”

News from Alaska shows the need to recommit to Wraparound principles

February 8, 2021 | Janet Walker

A series of recent articles in the Alaska News provides a sobering update to the story of a program that was one of the first to show success from the use of a Wraparound-type approach. In 1985, stakeholders from Alaska’s social services, mental health, and education departments formed the Alaska Youth Initiative. The AYI—managed by Wraparound pioneer John VanDenBerg–was successful in returning to Alaska almost all youth with high levels of mental health needs who had been placed in out-of-state institutions. At that time, Wraparound had yet to be defined or formalized, but the AYI work was firmly rooted in the key principles of individualization, unconditional care, and increasing family voice and choice. The documented success of the Alaska Youth Initiative was a key factor in the subsequent evolution and popularization of Wraparound.

The history of Wraparound since the AYI provides many examples of growth and success. A range of initiatives have demonstrated the positive outcomes that occur when Wraparound is done well, and collectively we have created an abundance of tools and resources to support that work. And yet, 35 years after the AYI, the Alaska News articles show that maintaining progress is not guaranteed. The most recent article reports that Alaska’s justice department has opened an investigation into whether the state unnecessarily institutionalizes children with behavioral health conditions, focusing on the high number of Alaska children who are sent to (mostly) for-profit, locked psychiatric treatment facilities in distant states. One earlier article detailed the wide fluctuations in the number of children being sent out of state since 2000, while another article featured the stories of young people who had been sent out of state, and their experiences being separated from their home communities. Thanks in part to lobbying by these young people, the state is feeling pressure recommit to community-based care. With the recent developments, improvements may be coming in Alaska, but the state’s experience is a cautionary tale about the ongoing work that may be needed to maintain the successes that Wraparound initiatives have produced.

Wraparound to be Reviewed by the Prevention Services Clearinghouse

January 15, 2021 | Eric Bruns

The national community of Wraparound providers, advocates, and Wraparound implementing states have reason to cheer some recent news from the federal Administration for Children and Families (ACF).

On January 5, The Title IV-E Prevention Services Clearinghouse, established as part of the federal Family First Prevention Services Act (FFPSA), announced that Intensive Care Coordination (ICC) Using High Fidelity Wraparound has been planned for systematic review.

The Prevention Services Clearinghouse was established by ACF within the U.S. Department of Health and Human Services (HHS) to systematically review research and evaluation on programs and services intended to provide enhanced support to children and families and prevent foster care placements.

Based on review of research evidence and level of available implementation supports, the Clearinghouse rates programs and services as well-supported, supported, or promising practices, in accordance with statutory requirements. As amended by the Family First Prevention Services Act, well-defined practices (e.g., mental health services, substance abuse prevention and treatment services, in-home parent skill-based programs, and kinship navigator programs) that are designated by the Clearinghouse as being supported by research evidence have a clearer path for being approved for funding under Title IV-E of the Social Security Act.

In Federal Fiscal Year 2022 and 2023, States with approved FFPSA Prevention Plans will need to ensure that 50% of their claims are for “supported” and “well-supported” programs; beginning in FY 2024, 50% of claims will have to be for “well-supported” programs.

Additionally, states cannot receive Title IV-E reimbursement for prevention services unless there is a well-designed and rigorous evaluation strategy for each service included in their five-year plan. However, the Children’s Bureau may waive the requirement for a well-designed and rigorous evaluation strategy for a well-supported practice if the State meets certain continuous quality improvement requirements in Family First.

Although well-supported practices must still be continuously monitored to ensure fidelity to the practice model and examine child/family outcomes, the waiver of a need to conduct a rigorous outcome study to demonstrate effectiveness lowers the bar (and, therefore, the cost) for the level of evaluation rigor that states must undertake, clearing the way for inclusion in state plans.

There is reason for hope for a positive review of ICC/Wraparound by the Clearinghouse: A recently completed meta-analysis of rigorous Wraparound research conducted by Jonathan Olson, Eric Bruns, and the University of Washington Wraparound Evaluation and Research Team (UW WERT) has shown that, across 16 controlled studies, Wraparound demonstrated significant, medium-sized effects on outcomes that are critical to child welfare agencies, such as prevention of youth out of home placement. Moreover, although the Clearinghouse’s standards differ, the Washington State Institute for Public Policy Child Mental Health Services Inventory, previously determined Wraparound to be research-based, facilitating its use in Washington under House Bill 2536.

The National Wraparound Initiative would like to salute the many states, centers of excellence, and others that nominated ICC/Wraparound using the materials the NWI prepared for this purpose. The consistency of terms and lists of relevant research studies included in those nominations were likely important factors in Wraparound’s inclusion in the Clearinghouse review. In the coming months, NWI will keep you posted on news from the Clearinghouse, as well as implications for states who seek to include ICC/Wraparound in state plans.

As always, if you have questions about the status of the Wraparound evidence base, or seek to use validated quality and fidelity tools developed by UW WERT, please feel free to email us at wrapeval@uw.edu. Information on training, coaching, and technical assistance can also be obtained via inquiries to these emails, or via the website of the National Wraparound Implementation Center (NWIC).

The HHS Children’s Bureau website for Title-IV-E Prevention Services provides information about the FFPSA Prevention Program, including links to the text of the legislation and federal guidance. From this website, the Title IV-E Prevention Services Clearinghouse and an Information Memorandum (ACYF-CB-IM-19-04) on Evaluation Development is also accessible.

Applying Implementation Science to Wraparound: What Should We Measure?

July 21, 2020 | Maria Hermsen-Kritz

Since early on in its history, the NWI has been promoting the idea that, in order for Wraparound to flourish at the level of child and family teams, numerous supportive conditions needed to be provided, not just within the “host” organization, but also by other collaborating organizations and within the larger system of care within which Wraparound “lives.” Over time, the NWI has renewed its focus on this issue and provided updates on recent research and tools relevant to this work.

The July 2020 webinar, “Applying Implementation Science to Wraparound: What Should We Measure,” is the latest such update. The webinar uses the lens of implementation science to describe key types of implementation support for Wraparound. Presenters also describe a full suite of assessments that can be used to gauge the extent to which key implementation supports are in place. These include well-known assessments such as the WFI-EZ, DART and TOM as well as newly-developed assessments to measure organization and systems support. Together, this represents a comprehensive assessment package that any Wraparound initiative can use to help ensure best outcomes for children and families. Along with the recording of the webinar and slides, we’ve posted a number of helpful resources for understanding Wraparound implementation supports and how to assess them. If you haven’t had an update on implementation issues and Wraparound recently, this set of materials is a good place to get one.

Supporting successful collaboration between youth partners and family partners in wraparound

June 30, 2020 | Maria Hermsen-Kritz

As the two peer providers on a Wraparound team, youth partners and family partners play a key role in ensuring the principle of youth and family voice and choice is upheld. But while their roles are similar in nature, when there is tension between a young person and their parent or guardian, the youth partner and family partner may feel like they are working on two separate teams.

Pathways and NWI recently released a practice brief addressing some of the ways youth partners and family partners can work collaboratively in order to support youth and families involved in the Wraparound process, as well as how to resolve some barriers that frequently arise. These included clarifying roles from the beginning, emphasizing the importance of confidentiality, working to promote positive communication between the youth and family, and using their lived experience to provide perspective to the team. The brief also included real-life scenarios and discussion questions and was accompanied by a study guide which provides answers to the questions. Download the practice brief and study guide here.

Staff from Pathways also participated in a webinar which covered the material from the practice brief. You can view the webinar and download the slides here.

Covid-19: Guidance from the New York Times

April 21, 2020 | Eric Bruns

Hello to our national Wraparound community of practice!

As many of you know, we have posted a piece of guidance from the NWI on implementing care coordination and other critical services to youth in need and their families in the era of COVID-19.

While it is most critical to follow your local community/state and organization’s guidance and expectations around providing care in the current context, I found the following piece from the New York Times, which compiled opinions from medical expects on the transmissibility of the virus, very helpful:

https://www.nytimes.com/2020/04/17/well/live/coronavirus-contagion-spead-clothes-shoes-hair-newspaper-packages-mail-infectious.html 

Be safe, be well, and take time for yourself. And be sure to wash your hands!

Eric Bruns

Virtual Technologies Work! Team-Based Supports and Planning

April 10, 2020 | John VanDenBerg, Ph.D.

Introduction. Team-based support and planning is nothing new. Over 130 years ago, Jane Addam’s Hull House used neighbors and friends to provide help for stressed families. Dozens of additional team-based planning, support and services innovations have been developed. This includes among many others, team-based support and planning processes such as Wraparound; Family Group Decision-Making; Restorative Justice Teams; The Open Table; and Circles of Support. As one of the founders of the Wraparound Process, and a consultant to The Open Table, I have spent much of the last 35 years spreading the word about team-based planning. 

When the COVID-19 virus appeared and was determined to be highly contagious, many individuals and community system of care leaders contacted me about what could be done to continue supports. My answers are summarized in this brief paper – I am convinced that as a field, we will respond like we always have, with innovation and dedication! This paper is not designed to teach details about each team-based planning and support process, but rather to share information about how to insert virtual technologies into these processes. Many team-based support and planning processes use different terms to refer to the “clients.”  In this paper, I use the term person/family to refer to those whom the support is focused on. 

Team-based planning and supports. There have been millions of individuals and families who have gone through team-based processes. At the heart of each of these innovations is a group of persons physically coming together with the person/family with needs, and then having face- to-face meetings on a scheduled basis. Clearly, in a time of limiting social contact due to COVID-19, these processes will be questioned and even discouraged. In a time of government prohibiting groups of people being together, we need team-based supports and meetings more than ever. Individuals and families who are already isolated and stressed can become even more isolated and stressed in times like these. 

Why we know a virtual approach can work! The field of distance learning (also called remote learning) was first developed over 165 years ago as a way of increasing the number of individuals trained to do shorthand. We now have numerous apps available to us to assist with virtual communication. 

As an international Wraparound consultant, I was often exposed to distance learning options. For example, in the mid 1990’s, in supporting Wraparound work in Saskatchewan (which is several times the size of Texas), the provincial authorities oriented me to sit in a studio in Regina and train groups all over the province. Their approach was laudable, because doing effective distance learning often requires learning new skills. 

For example, one of the skills involved in the Saskatchewan trainings was in-advance prepping with local group facilitators to ensure that the local groups could ask questions by passing a note to the local group facilitator, who then emailed the note to me. I would read the note and answer the question. As a result, the local groups felt truly part of the training process, and like any good trainer, I was able to mold the training to the needs of the remote groups.

Research on challenges and strengths of distance learning and virtual technologies. There have been numerous studies on the effects of distance learning and use of virtual technologies. This research identified challenges and strengths associated with distance learning and virtual technologies. 

Some of the challenges with distance learning/virtual technologies includes: 

  • It is harder to do initial engagement of persons with complex needs.
  • It can be harder to ensure strong group cohesion.
  • There is a need for strong facilitation to ensure individual team members participate.
  • Technology scares many people, or they don’t have access to technologies.
  • Individual team members may feel more comfortable not volunteering for individual tasks.

Some of the strengths of distance learning/virtual technologies includes: 

  • Having better access due to efficiency.
  • Increasing the number of persons served as a result of having a more efficient process
  • Lower costs due to reduced travel and meeting arrangements.
  • Increasing the number of potential team members willing to serve on a team, due to more efficient use of their time.
  • The need for more routinization of meeting processes, such as ground rules for meetings and methods of ensuring participation by all involved.
  • Ensuring a safe place. Participants report that they have an easier time maintaining emotional safety.
  • Time management. Overall, virtual meetings save transport and other logistical time use. In addition, virtual meetings can reduce distractions and help keep the group on task. 
  • Technology is better than ever. For example, few persons under 35 years of age are afraid of Facetime! The prices of assistive devices such as tablets are more reasonable than ever, and many people use their smart phones for virtual meetings. 

Facilitation. Almost all team-based planning involves use of trained facilitators. In High Fidelity Wraparound, facilitators learn team-support skills and are often formally certified as competent in facilitation. Many Wraparound teams ask the person/family to co-facilitate from the very first meeting. Many persons/family members will need support to learn virtual co-facilitation roles, but the message given to the team is one of how important the person/family is to the process of facilitation. 

Often, team-based planning facilitators have been trained to manage face-to-face processes but can be supported to quickly learn virtual team planning facilitation. However, especially in the area of ensuring team participation, virtual team planning requires learning new skills. 

Engagement challenges. Initial engagement of individuals and families with complex needs is very important to eventual outcomes. Often, in working with child welfare and juvenile justice agencies, I was awed by the engagement skills of staff, given the gravity of dealing with child abuse, neglect, or criminal behaviors. These skills involved body language, watching client reactions, emotional re-assurance, and dozens of techniques coming together to help a family begin their journey in these systems. Each of the team-based planning techniques involves training for strong engagement skills which can help a person/family start a journey towards healing. 

Can engagement be done virtually? Absolutely. Here are some defined skills and steps: 

 

  • First contact. The first engagement meeting can be done virtually for persons/families who are referred to team-based planning. The facilitator would make numerous advance phone contacts. On these calls, they would have “get to know you” time and share information about the team-based planning process. The facilitator would disclose details about their own lives and roles. In the old days, we were trained not to share details about ourselves, but although following good boundaries is important, no one would want to trust someone whom they do not know. In the Open Table model, this mutual disclosure has been proven to produce teams which continue to provide support long after formal graduation from the model. 
  • During these first contacts, the facilitator should ask the person/family about their preferences for team communication.  A wide range of potential options are available to meet person/family preferences. 

 

    • Ask the person/family about their communication preferences. Some persons who are very leery of technology may choose to use phone calls only, or choose to start with phone and add visual option such as Facetime at a later time. 
    • Others may not have any smart devices or computers or know how to use them. In these cases, assuming the person agrees, a team member can mentor the person/family on getting the devices either purchased or donated. A tablet is fairly inexpensive, and donations of tablets are available as people upgrade to new devices. Ideally, a program doing team-based planning will keep a supply of “loaner” devices. Family members who have graduated from team-based planning can be very helpful in mentoring new persons/families by phone or device.
    • The team member can brainstorm with the person/family about their preferences regarding acquisition of skills in virtual communications such as FaceTime, Zoom, Hangout, or other methods. 
  • Team composition. Most team-based planning methods stress the need to balance paid professionals and natural supports. Some models such as Open Table consist of teams that are all volunteers, with any paid professionals serving in consultation roles. In virtual team meetings, inclusion of natural supports is even more important than in non-virtual meetings. Teams should include graduates of team-based planning processes. For teams focused on the needs of families or transition-age youth or young adults, it is absolutely essential to have youth or young adult team members. 
  • Person/family preferences about meeting management. During first contacts, the facilitator can ask persons/families to share their preferences for how meetings are managed. Most persons/families involved in services experience dozens of meetings, involving the “good, the bad, and the ugly” of meeting processes and outcomes. The person/family needs to understand that this meeting is based on their preferences about how meetings should proceed. For example, the facilitator can introduce the topic of ground rules and person/family preferences about ground rules. A common ground rule in virtual planning is to ask the team members to be mentally present and involved, vs. being on their phones or doing other tasks during the meeting. A person/family may want one person to talk at a time or want initial meetings to include tight time schedules. 
  • Technology for virtual meetings. All team meetings would be done using remote meetings apps and technology (Zoom, Facetime, Google Hangouts, etc.). It is essential when using these technologies or remote meeting apps for the facilitator to have the skills of using the preferred method. We have all been on planned calls that aborted when the technology either failed or was not understood by the facilitator, or when the person/family was not prepared to use the technology. 

Larger sites with many persons/families involved with team-based planning may consider having a technology preparation specialist who mentors and oversees the process of preparing the person/family and the planning team for using the chosen technology. 

  • HIPAA compliance. Special attention to HIPAA compliance must be taken as needed by an organization. This paper is not meant to share how to ensure compliance, but I recommend awareness of this. 

Crisis management. As part of engagement, most team-based planning methods start with some initial examination of immediate crisis management needs, of major family needs, family culture, and strengths. In Wraparound, for example, most programs begin with initial crisis assessment and stabilization. This can be done via phone. In Family Group Decision Making, a safety professional works with the family to assess child safety, by asking the family and/or family networks about their perceptions of family safety issues. Often crisis assessment is done in the first engagement meeting but is also commonly done via phone interviews. 

Introduce the team in the first virtual meeting after engagement. In some methods of team-based planning, a team is in place and the person/family is matched with the team. This is the way the Open Table process is typically managed. Some communities working in juvenile justice have standing Restorative Justice Teams, but most team-based planning teams are individualized and are family-specific, such as with Wraparound and Family Group Decision Making. This step could be done via phone interviews, assuming some initial engagement has occurred. 

Ground rules. The person/family should have been asked about their preferences for ground rules for the group. In virtual teams, the need for ground rules may be greater than in the in-person group planning as group dynamics will not always serve to regulate team behaviors. Common ground rules for virtual planning include: 

  • Team members and the person/family must commit to being present at the meetings if at all possible, and if they cannot attend the meeting, to reviewing the agenda in advance and giving their input to the facilitator to share with the group at the appropriate time in the meeting. 
  • Be fully present and available for active participation – avoid other tasks, concentrate on the meeting, and avoid distractions to the group and to themselves.
  • Team members should let other team members speak without being interrupted. Take turns speaking by raising hands or if it is a phone meeting, by saying “I would like to comment,” which lets the facilitator call on the team member as soon as possible. 
  • Have a process, defined in advance, for re-joining the meeting if the team member loses connection to the group. Most meeting technologies such as Zoom have clear procedures for this. 
  • Strong facilitation. In virtual meetings, an overly enthusiastic or demanding team member can limit the effectiveness of the team meeting. Facilitators must exercise firm meeting management, without discouraging participation. Participation is monitored by the facilitator. In virtual meetings, it is easy for some team members to stay silent or simply avoid comments. 
  • Team members are asked to stay positive and to express concerns in a direct way without blaming or shaming the person/family or each other. 
  • Virtual meeting facilitation should include “going around the room” where each team member is asked to respond to encourage participation from everyone who is present. A common method of ensuring team participation is to ask team members to text the facilitator with questions or comments, and to text the entire team during the meeting as needed. Some of the team-based meeting technologies such as “Go to Meeting” have elaborate methods of capturing comments and questions.
  • Most team-based planning methods have ground rules about maintaining confidentiality. I recommend that part of the introduction time should include a verbal statement by each team member that they will respect confidentiality.
  • Most team-based planning methods have some version of “never about us without us” as a way of ensuring that individual team members do not discuss the person/family outside of the meetings. I recommend that this value be verbally affirmed by each team member during the introduction time.

Team cohesion and trust. Strong team cohesion and trust begins with team members and persons/families learning information about each other. This includes team members sharing who they are, why they are helpers, when they have needed help from others, what they can offer in the areas of special skills, and their goals for being part of team-based planning. This time is about establishing every team member not as the savior of the downtrodden, but rather as a person who also needs and gives support. At this time, the person/family can share their own definition of their major needs. Ideally, this information is recorded and available for new team members who may join the team. 

I recommend that the team have a process for team members who have to leave virtual meetings early. A team member should never just disconnect from the meeting — good meeting manners mean that the team member try to attend all of each meeting, and then if they have to leave early, let their fellow team members know in advance. 

Agendas. Almost all team-based support meetings use detailed agendas and time-limited meetings. Agendas are even more important for virtual meetings. Facilitators should work with the person/family to develop the agenda. Agendas must be shared with the person/family and team members in advance of the meeting. Facilitators must practice active monitoring of times used for each agenda item. Most team-based planning methods limit meetings to an hour or less. The quickest way to derail a team is to not follow an agenda and have meetings consistently go over the allotted time. 

Evaluation of team meeting effectiveness. Most team-based planning incorporates methods of informal or formal evaluation of the effectiveness of meetings. For example, an informal method may involve each team member and the person/family giving a 1-10 rating about how the meeting went, noting strengths and what could be done to make the meeting even better next time. A more formal method of meeting effectiveness may involve a separate evaluation filled out by each team member and the person/family and compiled by the facilitator. These ratings can be shared in the first part of the agenda for the following meeting. With virtual meetings, meeting effectiveness evaluation is even more important than in face-to-face meetings. 

Contact of team members with person/family outside of team meetings. Team-based supports and planning vary in how to handle person/family contacts outside Team meetings. For most team-based planning, frequent yet brief phone calls, email, and texting contacts with the person/family help build the ever-essential relationships which will sustain the planning over time. 

Summary.  Maximizing the use of virtual meetings and support is vital to the survival of team-based planning. This brief paper is designed to raise major issues involved with virtual meetings, and I encourage each locality to bring stakeholders together to develop and further refine how virtual supports and meetings will be done. 

Dr. VanDenBerg is one of the founders of the Wraparound Process, which is the dominant team-based planning process used in North America. He is currently retired from most Wraparound training and is a volunteer in supporting the Open Table, a national poverty intervention process similar to Wraparound. His email address is jevdb1@gmail.com. 

Wrapstat, the New Fidelity and Monitoring System, is Coming in September

March 9, 2020 | Eric Bruns

As someone who has attended the vast majority of the events since 1993, the cancellation of the 33rd annual “Tampa Conference” on Children’s Behavioral Health Research and Policy comes as sad news. It was at the Tampa conference that John Burchard and I gave our first presentation on the concept of wraparound fidelity.

That presentation was part of a symposium on fidelity assessment with Scott Henggeler, developer of Multisystemic Therapy at the 13th Annual conference… it is truly hard to believe that it has been 20 years since that first presentation! I guess that doing research is similar to being a parent: The days are long, but the years are short.

(Actually, it should be noted that in 1999, Ted Tighe and Janet Bramley developed the very first tool for assessing Wraparound teamwork: the Service Process Inventory for Families and Youth or SPIFY. Then as now, we loved our acronyms…)

Twenty short years (and 7,300 long days) later, Wraparound is in nearly every state. We have a national wraparound implementation center, there have been over 200 published research studies, and positive outcomes have been found in over 20 controlled outcomes studies.

Fidelity measurement has also evolved. We now have several fidelity tools and over 100 licensed users. While all the tools build on the basic concepts from the first Wraparound Fidelity Index, we have iteratively improved the reliability and validity of the measures, and now have hundreds of thousands of data points with which to conduct research and help initiatives, states, and organizations make sense of their own data.

At the same time, we have learned many times that wraparound fidelity and quality measurement is as susceptible as any construct to the phenomenon known as GIGO: Garbage In, Garbage Out.

We here at the UW Wraparound Evaluation and Research Team have had to repeatedly witness programs and sites collect “convenience samples” from a few families, and then report results that only represent the experiences of families that were easiest to reach, ignoring the perspectives of those who are struggling the most, or who disengaged early in the process.

Other sites have collected fidelity data with good rigor, and eagerly show their scores to stakeholders and the world… but yet cannot speak to the actual outcomes experienced by their youth and families. This despite the paramount importance of being able to report the rates at which young people enrolled in Wraparound are at home, in school, and out of trouble. Often, programs cannot even report the rate of successful discharge for their program.

Until recently, we have treated this problem as a training and consultation issue. And so, we provide guidance about needed sample sizes, representative sampling, and assuring good data collection and follow up success rates.

Now, we are on the cusp of launching a system that will do much of this with and for our collaborating Wraparound programs!

Later this year, WrapStat will replace our current WrapTrack data entry and reporting system for measures of the Wraparound Fidelity Assessment System (WFAS). After much thought, time, and effort from our wonderful UW WERT team, WrapStat is poised to aid any and all of our current and future WFAS users.

WrapStat was developed based on feedback from users on data elements and system functions needed to evaluate and improve Wraparound implementation. It also will facilitate research and help “make the case” for Wraparound impact at local, state, and national levels. Specifically, WrapStat will make it easier for users to:

  • Track enrollments, discharges, and basic youth demographics
  • Conduct randomized/ representative sampling of enrolled youth for Wraparound fidelity assessments.
  • Administer WFAS tools and track response rates
  • Monitor fidelity data and progress in real time
  • Prepare reports that best meet local needs

Whether your program is currently a WFAS measure licensee or not, we encourage you to check out our WrapStat one-pager or watch the short WrapStat video.

Twenty years after that first fidelity presentation, and 15 years since the initiation of the National Wraparound Initiative, we believe the launch of WrapStat represents yet another milestone in the continual evolution of Wraparound, its evidence base, and the robust community of practice that is the NWI.

Eric Bruns is a Professor of Psychiatry at the University of Washington, Director of UW WERT, and Co-Director of the NWI. He encourages you to contact the UW WERT team with any questions or thoughts about this blog post or WrapTrack by emailing wrapeval@uw.edu.

A Focus on “Fidelity” – When is poor adherence actually helpful adaptation?

January 21, 2020 | Eric Bruns

There is a phrase I often hear from the many implementation scientists I work with at the University of Washington School Mental Health Assessment, Research, and Training (SMART) Center. That phrase is: “there is no implementation without adaptation.” That is to say, when we take a research-based strategy into the real world, education leaders and school staff who are using it will always adapt it in some way to try to make it fit their own context and reality. Not only is this inevitable, it is often necessary to ensure success.

My colleague, Claire Crooks from Western University in Ontario, Canada, recently spoke of this phenomenon as it pertained to her own intervention, The 4th R. As she was presenting, I realized this trajectory could also easily be applied to Wraparound. Dr. Crooks describes the “fidelity trajectory” she has observed over the lifespan of interventions as follows:

Phase 1: The fidelity problem – A good idea (like Wraparound) is innovated and shows promise… but the field ignores fidelity guidelines or implementation parameters (or maybe they have not yet been developed). Poor implementation becomes the norm, outcomes fail to be replicated, and the field is ready to discard the once promising idea.

Phase 2: The fidelity “solution” –  To overcome “poor implementation” of the good idea, fidelity standards arise, and the field imposes rigid and doctrinaire implementation standards. This helps some programs achieve better outcomes, but other systems and organizations are left out, either due to high costs of implementation or a lack of “fit” between the strict standards and what they can achieve in their own systems. At the same time, the field learns ways to do the practice better that are not accommodated in the existing fidelity framework. People worry that the existing fidelity is outdated. Others worry about how to innovate and adapt given that the growing evidence base is based on the old fidelity framework.

Phase 3: Facilitate adaptation and model flexible implementation – community programs and researchers work together to determine how best to identify and retain the most critical elements of the program or strategy, while allowing changes to enhance fit to the system, organization, population of focus, or other element. Ideally, this helps assure the uptake of the program into more and more settings, without major compromises to the outcomes.

The Centers for Disease Control have described a heuristic for the “Facilitate adaptation” phase of a research-based program or strategy’s developmental lifespan, called the Traffic light framework:

  • RED: Unhelpful changes that remove critical elements that, for example, build skills needed for success in the client(s) being served

  • YELLOW: Changes that can be made with caution – perhaps to a program where the essential elements have not been identified

  • GREEN: Changes that enhance fit to the local context, but that retain the “essential elements” needed to achieve outcomes.

The above observations, and the “traffic light” analogy is no different in Wraparound than for school mental health strategies. The question is: What are the core elements? The National Wraparound Implementation Center (NWIC) focuses its training and coaching on four “essential elements” of Wraparound:

  1. Effective Teamwork,
  2. Strength- and Family-driven,
  3. Needs-based, and
  4. Outcomes-based.

Reflecting on this theme, John VanDenBerg observed in his 2016 National Wraparound Implementation Academy keynote that we probably already have some ideas on what is necessary to do “minimalist Wraparound”:

  • Rapid engagement and crisis response
  • Basing Wraparound plans on a small number of priority needs, described in the family’s voice
  • Building social support
  • Skill building for youths, caregivers, and family members
  • Monitoring and feedback of the plan and its strategies, family perspectives, and outcomes

Of course, just because we identify a smaller number of critical elements doesn’t mean they are easy to do. Rapid engagement requires low caseloads and flexible programs. Developing needs statements as per approaches promoted by NWIC requires skilled staff and flexible funding to “do whatever it takes” to meet those needs. Building social support for some families takes lots of effort and may require help from trained parent and youth peer partners. Skill building (e.g., for youth to manage stress or for parents to manage behavior) often requires availability of evidence-based treatments. And monitoring and feedback is facilitated by good data systems and supervision.

As Wraparound continues to evolve and mature, we should be careful to not be too doctrinaire about fidelity, and instead allow adaptation in local implementation efforts. We should also continue to do research on which practice and program elements are associated with the most consistently positive outcomes. The University of Washington Wraparound Evaluation and Research Team is currently working on a research protocol to do just that.

In the end, identifying core elements and facilitating helpful adaptation will aid our collective effort to make high-quality Wraparound available to as many youth and families in need as possible.

New Resource Adds to our Understanding of National Big Picture of Wraparound

December 5, 2019 | Janet Walker

I want to draw your attention to a new resource that is a valuable addition to our understanding of the national big picture of Wraparound. Last month, SAMHSA published a report entitled Intensive Care Coordination for Children and Youth with Complex Mental and Substance Use Disorders. Despite the use of the more generic term “intensive care coordination” in the title, the report mainly focuses on Wraparound, and provides information about implementation of programs in 40 states (and some smaller jurisdictions) grouped into three categories: sustainability phase, implementation phase and pre-implementation phase. The report contains specific information on eligibility criteria, evidence-based screening tools, evidence-based practices, credentialing requirements for care coordinators, integration with physical health care services, role of psychiatry in ICC, financing mechanisms including Medicaid vehicles and managed care organizations, rates and billing structure, staff training and tracking outcomes. This report not only provides a brief overview of the nation’s ICC implementation landscape but also details the specifics of implementation enabling interested states to expand and improve ICC strategies.

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