Wraparound Blog Archives - Page 4 of 5 - National Wraparound Initiative (NWI)

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 4^th 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 People worry that the existing fidelity is outdated.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.

Oregon’s Cultural Considerations Work Group

June 11, 2019 | Emily Taylor

In May 2018, I wrote a “call to the field” blog post about Mayra M. Perez Gonzalez, an evaluator in Puerto Rico, who had contacted NWI looking for more Spanish-language resources following Hurricane Maria. After that post appeared, we received a few responses from others who were also interested in Spanish-language materials.

One of those responses came from Otoniel “Tony” Calderon, a bilingual (Spanish and English) Wraparound Care Coordinator for Multnomah County Mental Health in Portland, Oregon. Multnomah County is the same county where I live, and where the NWI “headquarters” is located at Portland State University. I soon learned that Otoniel is a member of the Cultural Considerations Work Group (CCWG), a group of 15 multilingual and/or culturally-specific Wraparound practitioners here in Oregon, organized through the Systems of Care & Wraparound Initiative, also at Portland State. In the fall, I had the opportunity to join a CCWG meeting to speak with the members of the group and learn more about their work.

The CCWG began meeting in 2016, originally invited to provide culturally-specific consultation for the Oregon Wraparound Best Practices Guidelines. When the group began, individuals from 9 different counties and 11 agencies from across the state of Oregon were at the table. The CCWG members represented multiple cultures, including Mexican, Caribbean, Costa Rican, El Salvadorian, LGBTQ+, Latinx, African American, Japanese American, the Cherokee Nation of Oklahoma, and Jewish. The CCWG was very intentional about its work from the beginning. They used the Wraparound planning process to create team agreements, goals, and priorities to work on as a group.

Many CCWG members were the sole Spanish-speaking Wraparound practitioners within their agencies. In their work, they were expected to translate for youth and families during meetings, while simultaneously conducting these meetings in English for the non-Spanish-speaking providers in the room. Some CCWG members provided Wraparound to monolingual and bilingual Spanish-speaking youth and families without available Spanish-language materials for ten years. The group knew having translated documents would allow them to better serve the youth and families they work with, and help ease their overwhelming workloads, so they prioritized translating Wraparound documents their teams use from English to Spanish.

The group’s translation process was a collaboration completed during monthly meetings and through email over the span of 14 months. It was important that the words chosen for the translations were youth- and family-friendly and easily understood by the majority of Spanish-speakers. In many cases there were lengthy discussions about a single word to ensure the end result would be culturally responsive across various Latin cultures. Instead of using the formal Spanish taught in school, CCWG wanted to make sure to use the same Spanish the families they work with speak at home.

To date, the CCWG has finalized Spanish-language versions of the following four Wraparound documents: Wraparound Plan of Care, Wraparound 0-5 Strengths and Needs Summary, Wraparound 6-20 Strengths and Needs Summary, and Wraparound Crisis and Safety Plan. Currently, the CCWG is considering the best ways to share the Spanish-language resources they translated more broadly, in a way that ensures they will be periodically reviewed and updated.

The CCWG uses an equity lens to focus on racial, economic and social justice to analyze barriers being experienced by youth and families of color in Wraparound across the state of Oregon. Their focus encompasses all aspects of Wraparound practice, including hiring, retaining, and supervising culturally-specific Wraparound practitioners, and the organizational and systemic supports needed to provide culturally- and linguistically-responsive services to all youth and families.

In addition to completing translation of these Wraparound documents, the CCWG provided consultation on hiring and retaining bilingual and multicultural staff for the Oregon Wraparound Supervisors and Coaches Learning Collaborative. They are currently developing a survey to compare the work experiences, workloads, and needs of bilingual/multicultural Wraparound practitioners with those who are White/monolingual English-speaking to further inform the field. The group is also seeking potential funding options to continue their collaborative work.

Since its beginning, the group has been a source of support and knowledge sharing for its members. As Leti Ochoa, a member of the group and a Bilingual Wraparound Care Coordinator with Multnomah County Mental Health, described: “Spanish speakers are often an afterthought, but here at the CCWG they are at the forefront.” Group members report feeling validated, seen, understood and supported after attending the monthly CCWG meetings.

NWI recognizes the need for more materials in translation to Spanish and other languages and the importance of periodically reviewing and updating materials and translations to reflect the latest best practices and changes in language usage. NWI operates on a very small budget, but thanks to support from SAMHSA and NTTAC we’ve added to our Spanish-language materials. The Manual del usario del proceso de Wraparound (asistencia integral), the Spanish-language version of Wraparound Guide for Families has been updated, and we added Spanish-language versions of two other key documents from NWI: Conceptos basicos sobre Wraparound (asistencia integral) (Wraparound Basics), and Los diez principios del proceso de Wraparound (10 Principles of Wraparound).

I’m so glad the email request from Mayra M. Perez Gonzalez in Puerto Rico led me to the CCWG meeting, held in the same office building where I work so I could learn about this important work being done nearby.

For more information and to request copies of their translated materials for use in your work, contact the CCWG at culturallyresponsivelc@gmail.com. Here at NWI we’d love to hear from you about efforts to ensure Wraparound is culturally-responsive in your community, or if you just have thoughts and ideas on this important topic. Please add your comments below.

Wraparound and the Family First Prevention Services Act

May 14, 2019 | Janet Walker

With states working toward implementation of the new federal law, the Family First Prevention Services Act (FFPSA), there are new opportunities for using Wraparound to avoid placing children in foster care, to prevent placement disruption for children in adoption and kinship guardian homes, and to meet the mental health, substance use and related needs of at-risk children and their families/caregivers. If Wraparound is included in your FFPSA Prevention Services Plan, you could also use FFPSA training dollars to build provider capacity to deliver fidelity Wraparound and use FFPSA administrative dollars to support data systems, fidelity monitoring, quality and outcomes tracking.

If your state is interested in using Wraparound in its FFPSA Prevention Services Plan, don’t wait to see what ends up getting listed on the Children’s Bureau Clearinghouse. The Children’s Bureau has said repeatedly that they are eager to see what states want and propose for their plans. The Clearinghouse will be reviewing programs as they receive them – especially those submitted by the states – and producing ratings for different programs on a rolling basis.

Bottom line: Go ahead and include Wraparound in your prevention plan, even though it is not yet listed by the Clearinghouse. The more states that include it, the greater the likelihood it will end up on the list.

The NWI has compiled a brief information sheet on Wraparound and the FFPSA. The information sheet includes more information about the FFPSA, as well as information about the research evidence for Wraparound and where you can find Wraparound listed as an evidence-based or promising program.

Adapting Wraparound for Older Youth and Young Adults

January 17, 2019 | Janet Walker

Report: Adapting Wraparound for Older Youth and Young Adults

In mid-December, NWI and NWIC staff presented a webinar, and unveiled a new report, on adapting Wraparound for older youth and young adults. There were 660 registrants for the webinar, which provides an indication of interest in this topic. In the webinar, my colleague Caitlin Baird and I presented key findings from a qualitative research project that we had undertaken in the previous year. We wanted to explore Wraparound providers’ views on why and how they might change their practice when working with older youth and young adults. To do this, we sought out Wraparound programs and initiatives from across the nation that serve substantial numbers of young people over the age of 18. From these programs, we interviewed Wraparound facilitators and peer support providers involved in direct service to young adults, as well as managers of the programs. We wanted to address a series of questions, including these:

• What sort of adaptations were providers making?
• Did the adaptations that different providers were making resemble one another?
• How profoundly was practice altered as a result? And
• How systematic was the process of adaptation?
• How were practice quality and fidelity being ensured for the adapted practice?

The webinar and report answer most of these questions. We did find that the adaptations being made across providers and programs strongly resembled each other, which made sense since the adaptations responded to developmental differences between young adults/older youth and younger children in Wraparound. We also found that while practice was adapted significantly, providers were mostly confident that the adapted practice nonetheless adhered to Wraparound principles and fidelity guidelines. However, providers were not so confident about some areas of practice, and wanted clarification, particularly regarding expectations for teams (e.g., membership and frequency of meeting) and timing (e.g., how the phases of Wraparound might look different for youth and young adults). Further, providers were looking for guidance around how to ensure fidelity when practice is adapted.

If you are interested in this topic, I encourage you to read the report and/or view the webinar. Staff at the NWI and NWIC have made plans to follow up on some of the issues described above. We plan to mobilize our experts and develop a learning community to aid us in creating specific guidance around fidelity expectations. This should happen in the Spring of 2019, with a guidance document coming out after that. We will be providing further training and technical assistance during the National Wraparound Implementation Academy in September, and hope to see you there. Rooms at the Academy hotel are going fast!

Pre-Institute on Wraparound Supervision A Success!

September 18, 2018 | Emily Taylor

Approximately 40 Wraparound supervisors from around the country participated in the Pre-Institute Training “Supervision in Wraparound: Moving Beyond the Values and Principles,” one of six intensive two-day trainings held before the before the Training Institutes in July.

In this training, Kim Estep, NWIC Director, and Kimberly “Covi” Coviello, NWIC Assistant Director, challenged supervisors to think deeply about how they can best create a climate and culture that allows for quality Wraparound implementation. Participants walked through operationalization of the values and principles of Wraparound to create clear expectations of their teams.

“This group impressed me with their openness in sharing their experiences with one another, and their focus on learning new skills to take back to their organizations and states,” commented Kim Estep. “From their feedback, I think everyone walked away with renewed enthusiasm for partnering with families in Wraparound and using skill-based supervision for improved outcomes and greater staff satisfaction and retention.”

For those looking for more opportunities for Wraparound training, save the date for the next National Wraparound Implementation Academy (NWIA), September 9-11, 2019 at the Baltimore Waterfront Marriott.

Remembering Jonathon Drake

June 5, 2018 | Eric Bruns

Jonathon Drake

It is with great sadness that the National Wraparound Initiative announces the passing of a cherished member of its community. Jonathon Drake, 36, a longstanding NWI member and integral part of our national network of champions for youth with complex needs, died on May 23, 2018.

As described in his obituary, Jonathon was a husband, father of two boys, and a man of immeasurable integrity and bottomless kindness. His lifework was as a social worker at the University of New Hampshire’s (UNH) Institute on Disability. He was a Wraparound trainer and coach who focused on the school-based wraparound model called RENEW (Rehabilitation for Empowerment, Natural Supports, Education, and Work), including RENEW implementation for schools participating in the ongoing randomized controlled trial of RENEW funded by the Institute on Education Sciences.

Jonathon’s influence as a champion for youth and schools and his talent for facilitating trainings for school and mental health agency staff was recognized across the state, the country, and even internationally. Appropriately, Jonathon was honored as the first recipient of the New Hampshire Youth M.O.V.E. Rockstar Award in 2016. He was on track to complete his certification as a high school principal alongside his wife in the fall, and it was his dream to lead a New Hampshire high school one day.

For more on Jonathon, see videos of him facilitating a RENEW wraparound process in the influential documentary “Who Cares About Kelsey” at https://www.youtube.com/watch?v=YvHXZgKqlLs. You can see his profile page at the UNH IOD at https://iod.unh.edu/person/drake/jonathon.
The NWI will be working with UNH IOD on a lasting tribute to Jonathon, such as a scholarship or award in his honor. More information on how members of the NWI and Wraparound communities can donate to the cause will be forthcoming.

Call to the Field from our Colleagues in Puerto Rico – More Spanish Language Materials Needed

May 15, 2018 | Emily Taylor

As part of the NWI mission, we provide information, resources and tools to support Wraparound around the nation and around the world. Although we have been able to provide a Spanish-language version of the Wraparound Process User’s Guide, we recognize that there is a need for more materials in translation, into Spanish and other languages.

Mayra M. Perez Gonzalez

This need was reinforced recently when Mayra M. Perez Gonzalez, an evaluator with PR SOC Initiative III at ASSMC, the Administration of Mental Health and Addiction Services in Puerto Rico, contacted us. She explained that many of her team members and their clients are Spanish speaking, with limited English, so Spanish-language materials would be very valuable.

Since Hurricane Maria hit Puerto Rico September 20, 2017, life for many of its residents has not returned to normal. After months without power, it is estimated that more than 30,000 residents still have not had power restored. With damage from the storm estimated at $100 billion, many are still waiting for FEMA benefits. Meanwhile, more than 50,000 homes have nothing for roofs but blue tarps. Before Hurricane Maria, more than half of Puerto Rico’s population was already living in poverty. Since the storm, more than 200,000 residents have left the island for mainland U.S. and it is expected that many of them will not return. School enrollment data from six states receiving Puerto Rican children, shows that more than 22,000 children have been enrolled stateside since the hurricane.

These conditions would test the resiliency of anyone and research shows natural disasters can lead to PTSD, depression and suicide. Providers in Puerto Rico are seeing signs of increasing mental health concerns there. And hurricane season for the region starts again June 1.

Mayra wrote to us, "More than ever, I think that we need to implement the Wraparound model to the families in Puerto Rico. We have been surviving by the effort of the community-based groups. And without knowing it, they have been implementing the Wraparound model. Slowly but surely the everyday life has been moving on, especially in our impact area, the west of the island. But this is not the reality for the rest of the island. The power system is very fragile and we are grateful for resources sent to help in that area but still there’s a lot of work to do. And the hurricane season starts soon. We are still working hard to reach our families and their children with severe emotional disturbance. It would be so helpful if we had information in Spanish to easily explain the model."

We are calling on our NWI members and readers in hopes that collectively we can offer Puerto Rico some help in the form of Spanish-language Wraparound materials. If you have materials in Spanish to share, or are able to provide translation services, please contact us.

Increasing Youth Engagement in Wraparound: Findings from a Randomized Study of the Achieve My Plan Enhancement

March 23, 2018 | Janet Walker

This recent article by NWI/NWIC staff and colleagues describes findings from a randomized study in which half the participants got Wraparound “as usual,” and the others got Wraparound together with an enhancement that successfully increased youths’ engagement and active participation in Wraparound, as well as their alliance with the team. We’re pleased to be able to offer the full text of this article on the NWI website!

Here’s a summary of the article, as well as updates on where the AMP project has been up to since the randomized study was completed.

Achieve My Plan (AMP) is an enhancement for existing interventions and programs that is designed to strengthen providers’ skills in key areas that are typically needed for working successfully with youth and young adults. Specifically, AMP focuses on increasing providers’ capacity for working with young people in ways that promote their acquisition of self-determination skills, ensure that care/treatment is based on their perspectives and priorities, and highlight and build on strengths in meaningful ways.

AMP was originally developed and tested as an enhancement to Wraparound, which is a team-based planning and intensive care coordination process. Wraparound is intended to improve outcomes for children, youth and young adults with the highest levels of mental health and related needs, .and their families. Wraparound’s first principle stresses that the process should be built around the priorities and perspectives of the young person and their family; however, in practice, the young people’s “voice” is often not present to a meaningful extent. The AMP enhancement for Wraparound aims to increase young people’s satisfaction, active engagement and self-determined participation in Wraparound, as well as their alliance with their treatment planning team. Findings from a randomized study of AMP showed that, relative to youth who received “as usual” Wraparound, young people who received Wraparound with the AMP enhancement participated more – and in a more active and self-determined manner – with their teams. They also rated their alliance with their Wraparound teams significantly higher. Furthermore, adult team members in the intervention condition rated team meetings as being more productive, and they were more likely to say that the AMP meetings were “much better than usual” team meetings.

Since its initial development, AMP has been used to enhance providers’ practice within other interventions that include a focus on youth/young adult voice, strengths and self-determination. Current research on AMP is focused on documenting the extent to which training impacts providers’ competencies in these areas. Current AMP training is completely delivered via “remote” training and coaching (i.e., via a series of web conferences across several months, and via a secure internet video-based coaching platform) in a way that conforms to best practices. Specifically, to ensure that AMP training will be applied in practice, each group web conference is followed up with individualized coaching that incorporates observation of a provider’s work with young people and the provision of objective practice-focused feedback over time. This approach also allows trainees to learn and practice more basic skills (with coaching and feedback) before moving on to progressively more advanced skills.

Data was gathered from 67 trainees who have taken part in online training and coaching for AMP to date. Findings show significant improvements in trainee competencies for working with youth/young adults as assessed by their practice in video recordings, and as assessed subjectively by the trainees themselves. Trainees were also highly satisfied with the training/coaching experience. What is more, practice fidelity monitoring is organically integrated into the coaching process, so that no additional investment is required to track it.

A Study of Turnover among Wraparound Care Coordinators and Supervisors: Part II

July 17, 2017 | Janet Walker

Part II: Causes of turnover and retention

Part I of this blog post described why our staff at the National Wraparound Initiative (NWI) and the National Wraparound Implementation Center thought it was important to explore the issue of turnover among Wraparound care coordinators and supervisors. That post also described the national survey that we used to gather data about turnover, as well as some of the findings (what types of people responded, caseloads in their Wraparound programs, annual turnover rates, impacts of turnover).

In Part II, we continue on with reporting on some further findings. We asked our respondents to consider a list of possible causes of turnover among Wraparound care coordinators, and to select the ones they thought were "important" causes of turnover in their organization. Respondents were then asked to rank the causes they thought they were important. The chart below summarizes the responses.

As you can see in the chart, three causes of turnover – better job opportunities elsewhere, job stress and demands, and too much paperwork/bureaucracy – were selected by 70-80% of respondents as being important causes of turnover. Among these three causes, better job opportunities elsewhere was selected as the number one cause of turnover by just over 40% of respondents.

Causes of Turnover

The remaining causes of turnover were ranked as important by much smaller numbers of respondents, from around 40% for care coordinator skills not a good match for Wraparound to just over 10% for unfair treatment/feel unwelcome by supervisors or co-workers. However, the disparity between the percentages of respondents endorsing each cause as the number one cause of turnover was much smaller. In other words, while some causes of turnover are seen as important by many more respondents, a fair number of respondents see each cause as the most important one for their organization.

We asked respondents about causes of retention – things that make care coordinators attached to their jobs in Wraparound – in a similar way.

The chart below makes it clear that respondents think Wraparound care coordinators are most attached to their jobs for reasons connected to loyalty and commitments. This includes commitment to the children and families they work with, to Wraparound itself and to their co-workers and their organizations.

Contributors to Retention

When you compare the reasons for turnover to the reasons for retention, the contrast is quite striking. Respondents are saying that care coordinators stay in their jobs primarily because of the intangibles (commitments and loyalty) but are most likely to leave their jobs due to more tangible causes such as the opportunity to get a “better” job or the stress and demands of the care coordinator position.

Finally, we wanted to know if there was a relationship between respondents’ estimates of turnover in their organization and the turnover they reported for that same organization. We were a bit surprised to find only a very weak relationship between the two.

The survey provided us with a good base of information but left us with many questions about the causes of turnover and retention. We are currently wrapping up a series of follow-up interviews with selected survey respondents. Through these interviews, we are learning more in depth about these issues. We plan to present a webinar that summarizes our findings from the interview data in the Fall of 2017, so if you are interested, keep an eye on the website or our newsletter to learn about when that webinar will occur.

This document was prepared with support from the National Technical Assistance Network for Children’s Behavioral Health operated by and coordinated through the University of Maryland, and under contract with the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Contract #HH280201500007C. The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).