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

A Study of Turnover Among Wraparound Care Coordinators and Supervisors

June 12, 2017 | Janet Walker

Part 1: Description of the Study and Impacts of Turnover

"Staff turnover in mental health service organizations is an ongoing problem with implications for staff morale, productivity, organizational effectiveness and implementation of innovation, such as the introduction of evidence-based practices." (Aarons & Sawitzky, 2006, p. 289)

Staff from the National Wraparound Initiative and the National Wraparound Implementation Center are in frequent contact with stakeholders from Wraparound programs across the country, and there is no shortage of anecdotal evidence about the negative impacts that staff turnover can have on children and families, as well as on other staff in agencies that provide Wraparound.

The quote from Aarons and Sawitzky sums up the general perception in the field that turnover is an ongoing and serious problem. But surprisingly, there is relatively little research on turnover in human service organizations. The limited research that does exist has found that:

• Public mental health services typically experience turnover rates of at least 20-30%.
• The United States Department of Labor estimates the cost of replacing a worker is at least 33% of annual salary.
• Turnover’s impact on mental health clients has not been well investigated, but is assumed to be problematic.
• Organizational commitment and job satisfaction help to prevent turnover.
• Burnout is the most commonly cited cause of turnover in mental health services organizations, and burnout can be significantly influenced by organizational culture, as well as work-based social and professional support.

When we looked for studies and reports about turnover in Wraparound, we were not able to find enough information to address the many questions we had. For example: Are turnover rates in agencies that provide Wraparound similar to rates for other public mental health services? Is there wide variation in turnover rates, such that some agencies experience much higher and others much lower turnover? And if so, what are the factors that might contribute to that variation? Knowing the answers to these sorts of questions could suggest strategies that might be effective for retaining staff, increasing job satisfaction and, ultimately, contributing to a more experienced and more effective Wraparound workforce.

This line of reasoning led us to undertake a study focused on understanding more about turnover in Wraparound. In the early part of this year, we created an online survey about turnover, and recruited broadly for participants. In the early spring, we closed the study and began to analyze what we’d found. We are currently interviewing some of the survey participants to get a more in-depth description of what they think lies behind turnover and retention in their agencies.

This blog post is the first in a series that will discuss the findings from this research. This post will describe who took part in the survey, as well as their perceptions of the impacts that turnover has. In subsequent posts, we’ll go on to discuss the other findings from the survey and from the interviews.

We collected data during the winter of 2016-17, and got 331 complete responses. Respondents were primarily Wraparound care coordinators, supervisors and administrators. Respondents came from a total of 39 states and most reported that their agencies were located in large or medium metropolitan areas, though there were substantial numbers of respondents from small cities and rural areas as well.

One interesting finding was that more than two thirds of respondents reported that the caseloads for care coordinators in their agencies was 12 or fewer (i.e., in line with recommendations from the NWI), though the remainder reported higher caseloads.

We were somewhat startled to find that the average one-year turnover rate reported by respondents was just about 40%. However, turnover varied widely. Seventeen percent of respondents reported no turnover at all among care coordinators in their agencies during the past year, while almost a third of respondents reported more than 50% turnover. Another third of respondents reported turnover of 25-50%. Respondents also estimated that just under half of the turnover was accounted for by care coordinators leaving during their first year.

Percentage of Wraparound Care Coordinators Who Left their Jobs at Respondents’ Agencies During the Past Year

About 40% of respondents described turnover among Wraparound care coordinators in their agency as a serious problem. When asked about the negative impacts that turnover had, more than 80% of respondents said that turnover was a significant problem because children and families enrolled in Wraparound suffered when their care coordinators changed. Two-thirds of the respondents noted that turnover among care coordinators was a problem because it increased the workload for the remaining care coordinators, and about half of the respondents noted that turnover was problematic because it increased the workload for supervisors. About half the respondents noted that turnover among care coordinators was problematic because the quality of Wraparound provided was lower, and because turnover caused increased costs to the agency for hiring, training and orientation.

Next month, we’ll post more about the findings from the survey, including top reasons for turnover and retention.

What has your experience been regarding turnover among Wraparound care coordinators? Do you think it’s a problem and, if so, do you have ideas about what could be done to decrease turnover? Feel free to leave your comments and thoughts below!

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).

From Zero to 206 in 25 Years: The Wraparound Research Base Reviewed

May 9, 2017 | Eric Bruns

John Burchard

Twenty-five years ago this month, I traveled to Burlington, Vermont to visit the campus of the University of Vermont (UVM), and considered whether to accept its offer of graduate study in community and clinical psychology.

As I learned over the next four frigid years, the sunny, 65 degree weather that greeted me that day was not something I could expect on future spring days in northern New England. What did not disappoint me, however, was my decision that day to work with John D. Burchard, Professor of Psychology at UVM. John ultimately became a mentor, friend, and my greatest role model for leading a principled, outcome-focused career and life.

When I traveled north from Virginia in 1992, John’s paper on Project Wraparound in Vermont was the only published academic paper on what were then called “Wraparound services” for youth with complex behavioral health needs and their families¹. John’s trailblazing work inspired me during graduate school to study individualized, family-driven service models, and how systems can invest in such shifts in service delivery. My dissertation was the first-ever controlled study of the impact of respite care.²

As John’s health declined in the early 2000s, John, his wife Sara, and I wrote a chapter on Wraparound in a book Edited by Barbara Burns and Kimberly Hoagwood³. This experience inspired me to come back to Wraparound as a research topic, and find others with whom to further build the research base. By then, over a dozen studies on Wraparound had been published, including a couple of randomized control studies,^{4 5} and momentum was growing to develop and support new ways to keep youth “at home, in school, and out of trouble.”⁶

Where is the Wraparound research base now?

A systematic review of Wraparound research just published in the Journal of Child and Family Studies and led by Jennifer Schurer Coldiron on our University of Washington Wraparound Evaluation and Research Team found that, as of 2014, 206 peer-reviewed publications had been published on Wraparound. Below are just a few of the authors’ findings from this new review:

• The rate of Wraparound research has been accelerating over time. As shown in the accompanying figure, 10 to 20 papers on Wraparound are now typically published every year. It seems that Wraparound is far from a passing fad, as was a concern around the turn of the millennium.
• Wraparound has been the subject of 22 controlled studies, 15 of which showed positive results of Wraparound compared to the control or comparison condition. Although several studies found no differences between conditions, none of the 22 studies found better outcomes for the comparison group.
• Implementation quality and fidelity measurement has only become commonplace among published outcomes studies in the last few years. Among studies that found null results and actually measured implementation quality, lack of adherence to the Wraparound model was typically a main reason Wraparound did not improve outcomes over services as usual.
• Relatedly, an emerging body of research is demonstrating the importance of adhering to specific principles of Wraparound care in order to achieve outcomes. Research is also finding that without achieving certain types of program- and system-level standards (e.g., caseloads, training and supervision, funding flexibility), youth and system-level outcomes are likely to suffer.
• Cost-effectiveness studies are not typically conducted with rigor; however, several such studies⁷ make a compelling case for Wraparound’s ability to dramatically shift service use patterns toward more community based care and reduce overall costs of services.
• Eighty-four of the 206 papers on Wraparound were non-empirical “thought pieces” that described the practice model or made the case for Wraparound. Interestingly, the proportion of non-empirical papers published every year does not seem to be declining over time. We speculate that Wraparound’s capacity to serve as an “operating system” for coordinating care for many types of individuals and system contexts has led authors to continue to propose new and novel applications of Wraparound for people with complex needs. Of course, it could also be that youth- and family-driven, strengths-based care is still viewed as a “fringe” idea, one that requires continued advocacy.

Despite the growing number of publications, the review also found many gaps in our understanding that point to an array of research studies left to be done. Some topics that need more attention include:

• More on Wraparound’s mechanisms of positive change. As the human services field shifts increasingly toward system-level integration, Wraparound has a lot to offer the conversation about what care coordination practices are most important to achieving outcomes. Our team has proposed that practice elements such as being youth- and family-determined, individualized, and needs- and outcomes-based are applicable to any type of care management model, at any level of intensity. Research that explores this assertion more rigorously and systematically could greatly aid the development and support of care coordination models in all types of health care settings.
• Relationship of the service array to outcomes. While some pilot studies have asked about how best to integrate evidence-based clinical practices and Wraparound⁸, little rigorous study has asked about the impact of investing in specific types of services or workforce development for staff in other provider roles. Given how little attention many systems of care pay to the breadth or nature of formal services in the continuum of care, such research may help provide guidance – and motivation – to do so.
• Implications of policy, financing, staffing, administrative, and system conditions. Our National Wraparound Implementation Center (NWIC) has now provided training, coaching, and system-level technical assistance to over 10 states. As a result, we have data that indicates certain types of system structures (such as Care Management Entities⁹) are associated with better youth and family-level practice. Much more understanding in this area is needed to help guide system-level reforms and refinements in states and communities.
• Workforce Studies. With help from nationally renowned trainers and experts, NWIC has developed a sophisticated training, coaching, certification, and implementation support model that uses data to adjust over time. However, even we cannot be sure how best to continue to evolve this model, or how much effort is worth investing in what areas, without more rigorous research on topics such as supervision, data-informed coaching, staff selection, staff training, and methods of providing technical assistance.
• More on family and youth peer support. Remarkably, given our dedication to being youth and family driven and to incorporating youth and parent peer support wherever possible, only three of the 206 studies focused on this topic.

Although the Wraparound research base – and research base for care coordination more generally – would benefit greatly from additional study, Coldiron, Bruns, & Quick (2017) nonetheless concluded that the Wraparound literature produced to date has provided a wealth of useful information. It has explicated and tested (somewhat) Wraparound’s theory and core components, its program and system supports, and applicability across systems and populations. It has begun to unpack relations among system, program, and practice elements and outcomes.

Most important perhaps, the review suggests that we now have a reasonable basis for concluding that, when implemented well, and for an appropriate population, Wraparound is likely to produce positive youth, system, and cost outcomes. In short, Wraparound is research-based. We think John Burchard would be pleased to see how far Wraparound – and those who have endeavored to provide it and promote it – have come.

Figure 1. Annual and Cumulative Wraparound Publications

We invite you to read this review of research, and to let our team at the National Wraparound Initiative know if your Wraparound initiative or system of care provides an opportunity for us to answer any of the above questions. In the meantime, be on the lookout for future installments of this Wraparound Blog, from the National Wraparound Initiative and its many collaborators.

Humboldt County Wraparound Unit in the News

April 7, 2017 | Emily Taylor

The local Times Standard newspaper in Eureka, Calif. recently highlighted the Humboldt County Wraparound Unit for its work with local at-risk youth. In April 2016 Children and Family Services staff there began training as Wraparound coordinators and coaches, and since then several staffers attended the National Wraparound Implementation Academy and received additional training provided by National Wraparound Implementation Center last fall.

The Wraparound unit team members included in this photo published with the original article, are (from left): Tim Johnson, Candice Campbell, Marshall Boyett, Heidi Young, Trevlene Blood, Donna Filippini, Dani Widmark and Corina Keppeler.