Connecticut TF-CBT Learning Collaborative
Year 3 Report
Jason M. Lang, Ph.D.
Robert P. Franks, Ph.D.
Connecticut Center for Effective Practice
Connecticut TF-CBT Learning
Collaborative
Year 3 Report
July 2009 – June 2010
Jason M. Lang, Ph.D.
Robert P. Franks, Ph.D.
Connecticut Center for Effective Practice
Child Health and Development Institute
April 1, 2011
This report was developed for the Connecticut Department of Children and Families (DCF) as a
publication of the Connecticut Center for Effective Practice (CCEP). CCEP is directed by
Robert P. Franks, Ph.D., under the auspices of the Child Health and Development Institute
(CHDI) of Connecticut. CCEP’s advisory board includes the Connecticut Department of Children
and Families, FAVOR, the Judicial Branch Court Support Services Division, the University of
Connecticut Health Center, and the Yale University School of Medicine. CCEP is supported
through funding from the Connecticut Department of Children and Families and the Children’s
Fund of Connecticut.
TABLE OF CONTENTS
Introduction ..................................................................................................................1
Faculty & Planning Team.............................................................................................3
Coordinating Center Deliverables................................................................................4
Staff Trained and Families Served ..............................................................................5
Data...................... .......................................................................................................7
Intranet.........................................................................................................................8
Year 3 Results .............................................................................................................9
Challenges & Barriers to Implementation ..................................................................15
Successes .................................................................................................................18
Conclusions ...............................................................................................................22
Recommendations.....................................................................................................23
Six Month Follow-up Addendum................................................................................26
Appendix 1.................................................................................................................27
Appendix 2.................................................................................................................28
INTRODUCTION
Overview
The Connecticut Trauma Focused Cognitive Behavioral Therapy (TF-CBT) Learning
Collaborative is a three-year initiative funded by the Department of Children and Families
(DCF) to disseminate TF-CBT to community mental health agencies across Connecticut. TFCBT is an evidence-based, short-term, family-centered mental health intervention for children
and adolescents suffering from traumatic stress symptoms. TF-CBT has been designated a
Model Program by the Substance Abuse and Mental Health Services Administration
(SAHMSA), and clinical trials have shown that TF-CBT results in significant symptom
improvements for youth exposed to trauma. However, past efforts to disseminate evidencebased practices (EBPs) in community settings have had limited success because of the
inherent challenges of transforming organizational policies, procedures, and systems. Barriers
to implementation of EBPs include inadequate funding, limited training time, little or no followup consultation, clinician resistance to EBPs, limited buy-in from administrators, lack of data
measuring progress and outcomes, little or no quality assurance, and organizational, state, or
federal policies that impede EBP adoption.
The Learning Collaborative is a quality improvement model developed by the Institute for
Healthcare Improvement, and adapted by the National Child Traumatic Stress Network
(NCTSN). The Learning Collaborative model was designed to address these barriers and to
facilitate the dissemination and adoption of best practices through system-wide change.
Connecticut is one of the first states to utilize this method on a statewide level to disseminate a
behavioral health EBP.
The Connecticut TF-CBT Learning Collaborative began in July 2007. This report is a summary
of the third year and final year of the initiative, covering the period from July 2009 through June
2010. This report primarily focuses on activities and data from the third year, but also
summarizes the three year initiative and includes a 6-month follow-up addendum summarizing
results through December 2010.
What is a Learning Collaborative?
A Learning Collaborative is typically a year-long process that differs from traditional training in
several ways. First, a Learning Collaborative includes staff from various positions within an
agency and staff from multiple agencies learning together. Clinicians, supervisors, and
administrators (referred to as senior leaders) from each agency participate for the entire
training period, which is typically one year. This process provides opportunities to address
barriers to implementation at multiple levels and allows staff to share experiences and learn
from peers in similar roles at other agencies. Second, a Learning Collaborative typically
includes multiple in-person trainings, an active intranet site, and regular consultation calls over
the year so that clinical skills can be reinforced and barriers to implementation can be
addressed during each agency’s initial implementation process. Separate consultation calls for
clinicians, supervisors, and senior leaders are provided to focus on salient issues for each
group. An intranet site is used for members to post questions and share ideas. Third, a
Learning Collaborative builds capacity for quality assurance and the use of data to improve
treatment by training staff to utilize ongoing assessments at the client, clinician, supervisor,
and agency levels. Finally, in the Connecticut TF-CBT Learning Collaborative, the role of the
family partner was introduced to provide a consumer perspective to the implementation of TFCBT. Each agency identifies a family partner from their community to participate on the team
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Connecticut TF-CBT Learning Collaborative: Year 3 Report
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throughout the Collaborative year.
Goals and Expected Outcomes
The overall goal of the Connecticut TF-CBT Learning Collaborative is to improve access to
evidence-based treatment for children and adolescents suffering from PTSD and other
traumatic stress symptoms and to make evidence-based trauma-focused services available to
children and families across the state of Connecticut. The following outcomes were identified
as being important for meeting this goal:
1. Universal screening for trauma exposure within participating agencies
2. Increasing TF-CBT capacity within agencies
3. Clinical competency in TF-CBT among clinicians
4. Supervision by supervisors experienced in TF-CBT
5. Adequate treatment fidelity
6. Routine use of data to monitor progress and inform treatment decisions
7. Agency leadership supportive of implementation
8. Core TF-CBT team that meets weekly to promote implementation
9. Sustainability of TF-CBT following the Collaborative year
10. Improved agency capacity to sustain and adopt EBPs
11. Developing a network of TF-CBT sites in Connecticut
12. Development of a trauma-informed, TF-CBT trained workforce
13. Building capacity of TF-CBT experts and champions in Connecticut
14. Caregiver involvement in treatment
15. Consumer involvement in all aspects of the implementation
16. Positive child outcomes
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FACULTY AND PLANNING TEAM
A Learning Collaborative typically includes several faculty members who develop the overall
training plan, provide training in clinical competencies and implementation, and monitor
progress throughout the initiative. The faculty of the Connecticut TF-CBT Learning
Collaborative is listed below.
Robert Franks, Ph.D. is the Director of the CCEP and is the Project Director of the TF-CBT
Learning Collaborative. He oversees the initiative and conducts the Senior Leader track
breakouts and conference calls.
Jason Lang, Ph.D. is an Associate Director of the CCEP and is the Project Coordinator of the
TF-CBT Learning Collaborative. He runs the day to day operations of the project and provides
training and technical assistance to sites on continuous quality improvement.
Carrie Epstein, LCSW-R is a national TF-CBT Train-the-Trainer who has participated in
multiple TF-CBT Learning Collaboratives. She is an Assistant Clinical Professor and Director
of Training for the Childhood Violent Trauma Center at the Yale Child Study Center. Ms.
Epstein is the lead faculty TF-CBT trainer in this initiative.
Carla Stover, Ph.D. is an expert in child trauma and an Assistant Professor at the Yale Child
Study Center. Dr. Stover’s role in the Learning Collaborative is to provide training in
assessment of children and in the TF-CBT model.
Doriana Vicedomini is the Faculty Family Partner of the Learning Collaborative, and oversaw
the family partner track during the third year of the initiative.
Merva Jackson, BSW is the Executive Director of AFCAMP, a family advocacy organization in
Connecticut. She was the Faculty Family Partner of the Learning Collaborative, and oversaw
the family partner track for the first two years of the initiative.
Marilyn Cloud, LCSW is the DCF program officer for the initiative. Ms. Cloud participates in the
Senior Leader track, acts as a liaison between agencies and DCF, and facilitates awareness of
the TF-CBT initiative among DCF staff across the state.
Jan Markiewicz, M.Ed. is the Training Director at the National Center for Child Traumatic
Stress at Duke University, and she has conducted over 30 Learning Collaboratives nationally.
She consults on this initiative to develop the family partner and senior leader tracks.
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COORDINATING CENTER DELIVERABLES
The Coordinating Center, CCEP, was responsible for serving two primary functions during
Year 3 of the TF-CBT Learning Collaborative initiative: 1) training staff from six new agencies
and 2) providing ongoing technical assistance and support to staff from the ten agencies who
participated in the first two years. CCEP produced the following deliverables during Year 3:
1. Developed a comprehensive year-long training plan for the six new agencies based on
feedback from prior cohorts
2. Completed initial site visits with new agencies, and follow-up site visits with agencies
from Years 1 and 2 to promote sustainability of TF-CBT
3. Provided seven full days of in-person training for staff
4. Provided one full day of training for family partners and site coordinators
5. Provided weekly consultation and technical assistance to TF-CBT teams at participating
agencies through calls with site coordinators
6. Provided separate monthly consultation calls for clinicians, supervisors, and senior
leaders
7. Maintained online intranet site for sharing information and technical assistance
8. Reviewed and provided feedback on clinical and case materials submitted by agencies
to promote fidelity to TF-CBT
9. Collected, analyzed, and reported monthly metric data about implementation for the
new and existing agencies
10. Collected, analyzed, and reported agency implementation data
11. Convened a statewide TF-CBT conference attended by over 150 staff in April 2010
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STAFF TRAINED AND FAMILIES SERVED
Staff Trained
During Year 3, six agencies were awarded DCF contracts to participate in the Learning
Collaborative following a competitive Request for Proposals (RFP) process. DCF awarded
each agency $31,600 for the year to offset training costs. The agencies trained during the
three-year initiative were:
2009 - 2010
• Bridges, A Community Support System
• Child and Family Agency of Southeastern CT
• Child Guidance Center of Central CT
• Charlotte Hungerford Center for Youth and Families
• Community Health Center
• Hill Health Center
2008 - 2009
• Child Guidance Clinic of Southern CT
• Family Services of Greater Waterbury
• The Village for Families & Children
• Wellpath
2007 - 2008
• Clifford Beers
• Community Health Resources
• Family & Children's Aid
• Klingberg Family Center
• United Community and Family Services
• Wheeler Clinic
The 10 agencies who participated during the first two years of the initiative continued to
receive technical support and training through the Coordinating Center and continued to
provide TF-CBT. Most of these 10 agencies also added TF-CBT team members, who were
trained by existing team members at their agency and at the statewide TF-CBT conference.
The following table summarizes the number of staff trained in TF-CBT during the third year of
the initiative, and for the entire three years:
Position
Clinicians
Supervisors
Sr. Leaders
Family partners
TOTALS
Lang & Franks
2007 – 2009
Cohorts 1 & 2
Staff Trained
103
27
20
10
160
2009 - 2010
Cohorts 1 & 2
Cohort 3
Staff Trained Staff Trained
54
1
1
0
56
Active Staff
as of
6/30/10
Total Staff
Trained
2007 – 2010
135
27
18
3
183
189
38
28
16
271
32
10
7
6
55
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A number of other staff at participating agencies, and other community members, have also
been directly or indirectly involved in the TF-CBT initiative. For example, intake staff have been
briefed about TF-CBT and how to screen for trauma exposure and additional staff have
received training in TF-CBT so that they can refer appropriate children to the TF-CBT team.
For example, several agencies now require every new clinician to minimally complete the 10hour web-based TF-CBT training course. Nearly all agencies have expanded their TF-CBT
teams by bringing new clinicians to the core team or identifying new practice areas for
implementation of TF-CBT.
In addition, staff from CCEP and the agencies providing TF-CBT have provided training to
DCF area office staff across the state throughout the three year initiative. These trainings
typically include an overview of child traumatic stress and TF-CBT, guidelines for DCF staff to
identify appropriate referrals for TF-CBT evaluation, and how to make referrals to an agency
providing TF-CBT in the community.
Children and Families Served
As of June 2010, a total of 985 children and adolescents have been identified as appropriate
for TF-CBT and have received at least one TF-CBT session. This includes 205 children and
adolescents seen by the six Year 3 agencies, 271 children and adolescents seen by the four
Year 2 agencies, and 188 children and adolescents seen by the six Year 1 agencies from July
2009 through June 2010. The Year 1 agencies provided TF-CBT to 358 children in the two
years following their training (July 2008 – June 2010). The Year 2 agencies provided TF-CBT
to 271 children in the year following their training (July 2009 – June 2010). The number of
cases seen is likely an underestimate because it excludes clinicians who left their training
agency and who may still be providing TF-CBT elsewhere, and excludes TF-CBT cases that
staff may not have reported in the monthly metrics.
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DATA
The use of data at the client, therapist, and agency levels is a fundamental component of the
Learning Collaborative methodology. In the Learning Collaborative, "measures" are client-level
symptom data and "metrics" are clinician- and agency-level data about TF-CBT
implementation.
Measures
Therapists are required to use the UCLA Posttraumatic Stress Reaction Index (PTSD-RI) and
the Short Mood and Feelings Questionnaire (SMFQ) with each client and his/her caregiver.
These measures are administered pre-treatment, every three months, and at discharge. A
client satisfaction survey is also administered to caregivers every three months and at
discharge. These data are used for assessment and evaluation of potential TF-CBT cases, to
measure client progress over time, and to drive treatment/discharge decisions. Symptom data
are shared with clients and caregivers regularly during treatment to discuss progress. A
computer scoring system was developed for the Learning Collaborative that provides clinicians
with a summary of each assessment to facilitate clinical use of assessment data and for
sharing with families (see Appendix 1).
Metrics
Clinicians complete monthly metrics to assess, evaluate, and promote the implementation of
TF-CBT at each agency. Metrics include data about each clinician's experience assessing
cases for TF-CBT, TF-CBT caseload, supervision, and skill/competency in the TF-CBT
components. Information is also provided about each TF-CBT case, including caregiver
involvement, number of sessions, and use of various TF-CBT components. A sample metric
report is provided in Appendix 2.
Data Challenges
Facilitating data use at community clinics is especially challenging because of (1) negative
past experiences of submitting data; (2) anxiety about using and interpreting data and
measures; (3) the additional burden data collection puts on clinicians; (4) the additional burden
data collection puts on clients; (5) perception that data is for research and is not helpful for
treatment.
Several data innovations were developed for the Learning Collaborative to address these
barriers. The data systems were designed to ensure that data was useful to clinicians and
families, that additional burdens were minimal, to build organizational capacity for data use,
and so that data could be monitored by the Coordinating Center. The data management
systems include:
(1) Online data entry and scoring of clinical measures, using only de-identified data
(2) Immediate feedback/score summary provided in a family-friendly format
(3) Online entry of monthly clinician metrics
(4) Metric summaries provided to all staff monthly
(5) Real-time monitoring of all data by the Coordinating Center
(6) Secure online data management system
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INTRANET
The TF-CBT Learning Collaborative intranet site was developed to facilitate dissemination of
materials and to allow all current and former participants to share information. The intranet site
was developed on Google Groups, and subsequently moved to Google Sites, which provide a
private, members-only site at no cost. The intranet serves as the central hub of the Learning
Collaborative, and participants are encouraged to access the site regularly for updates.
Features of the intranet include:
1) The Coordinating Center manages the site, including who may access the site and what
material is presented on the site.
2) All Learning Collaborative participants may access the site from any computer, 24 hours
per day.
3) Faculty members typically respond to posts/questions within 24 hours.
4) The Coordinating Center can easily post notices, updates, and training schedules that are
visible to all members on the main page.
5) All members may upload files to share with others. For example, the Coordinating Center
uploads clinical screening measures and other training materials, and clinicians may upload
a clinical tool they developed for implementing a component of TF-CBT.
6) All members may post questions on a private discussion board. Posts have included
clinical implementation questions posed to the group, responses to consultation calls, and
requests for help problem-solving organizational barriers to implementing TF-CBT.
7) Members can elect to receive emails whenever new posts are made, or can choose to login
to the site manually.
8) Members can view up-to-date TF-CBT site rosters and request changes to their agency’s
list of rostered clinicians via an online form.
9) The intranet site can remain active indefinitely with minimal support to maintain
membership lists and provide updates.
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YEAR 3 RESULTS
1. Trauma Screening
As of June 2010, the six Year 3 TF-CBT agencies reported that 100% of children presenting
for intakes were screened for trauma exposure. Universal trauma screening is important for
identifying child traumatic stress in children who may be referred for a variety of problem
behaviors. Children who screen positive for trauma history typically receive further assessment
by a TF-CBT clinician to determine appropriateness for TF-CBT. Most of the ten agencies from
Years 1 and 2 no longer report screening rates to the Coordinating Center because of
reductions to their site coordinator’s time and limited ability to collect this data consistently
following the training year. At the time these ten agencies last reported screening data, over
95% of the children presenting for intakes were screened for trauma history. Senior leaders
report that their agencies have continued to screen for trauma exposure systematically by
incorporating trauma questions into their intake procedures.
2. TF-CBT Capacity
A total of 664 children and adolescents received TF-CBT from July 2009 through June 2010.
As of June 2010, there were currently 254 TF-CBT children receiving TF-CBT across the 15
agencies reporting metric data. As shown below, the number of children receiving TF-CBT has
continued to increase. The total TF-CBT capacity is estimated to be approximately 350-500
children receiving treatment concurrently, but could increase with additional trained staff if
necessary. Incorporating new clinicians onto the TF-CBT team and spreading TF-CBT to other
practice areas, which all teams have continued to do with various degrees of success, will
build additional capacity.
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3. Clinical Competency in TF-CBT Components
TF-CBT consists of nine components that are recommended by the treatment developers as
necessary for completing TF-CBT (with the exception of in vivo exposure, which is optional).
Clinicians’ ratings of their comfort and skill providing these components, as well as their use of
symptom measures and their ability to share assessment data with families, over the course of
the training year are shown below. These data show the month-by-month improvement of Year
3 clinicians’ skill and comfort in every one of the components from September 2009 through
June 2010. Many clinicians continue to progress through the TF-CBT components with the
children they are serving. It is expected that as clinicians complete several cases, their
skill/comfort with the model will continue to improve. In addition, the average skill level of
clinicians will fluctuate over time as agencies lose experienced team members and add new
TF-CBT clinicians.
The following graph shows the increases in skill/comfort for all active clinicians from all three
cohorts from September 2009 through June 2010:
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4. Supervisor Capacity for TF-CBT
Each of the ten agencies has from 1-4 clinical supervisors who participated on the TF-CBT
team. As of June 2010, each clinician for the Year 3 sites received an average of 5.4 hours of
monthly TF-CBT supervision at their agency. Clinicians from the Year 1 and Year 2 sites
received an average of 2.8 and 4.1 hours of TF-CBT supervision per month, respectively.
Supervisors participate in a dedicated supervision track that includes supervisor-specific
consultation at the Learning Sessions and on monthly supervisor-only and supervisor/senior
leader consultation calls. Every supervisor is also required to provide TF-CBT directly to build
their clinical expertise in the model. Teams are required to develop plans for sustainability of
TF-CBT that include building supervisory capacity and ensuring adequate supervision of new
and experienced TF-CBT clinicians. Supervisory capacity within six agencies was also
enhanced through participation of a TF-CBT Fellow, who received advanced training and
consultation with the faculty.
5. Adequate Treatment Fidelity
The Learning Collaborative promotes a culture of fidelity to the TF-CBT model throughout the
training year with the goal being that responsibility for maintenance of fidelity is shifted to each
agency toward the end of the training year. Supervisor track calls and breakouts focus on
maintaining fidelity of staff they supervise, clinician calls focus on maintaining fidelity, and the
senior leader track includes training on agency-level monitoring and assessment of fidelity.
Clinicians and supervisors are provided with a treatment fidelity checklist to use during
supervision that allows for assessment and discussion about TF-CBT fidelity. Aspects of
treatment fidelity are also monitored by the Coordinating Center. Clinicians complete a brief
fidelity checklist for each client in their monthly metric. This requires clinicians to consider their
use of the TF-CBT components and allows agencies to assess progress of cases through the
model. Clinician ratings on this self-report indicator suggest that they are generally maintaining
fidelity to the TF-CBT model.
The mean length of treatment for completed cases is 21.5 sessions of 45-50 minutes each.
This length of treatment is consistent with the treatment guidelines for TF-CBT, which suggest
that treatment should typically be completed in 12-16 sessions of 90 minutes each. Preliminary
outcome analyses on child symptom data (described in detail below) that show significant
improvements on PTSD and depression symptoms for children completing TF-CBT further
suggest that fidelity is being maintained.
6. Routine Use of Data to Monitor Progress and Inform Treatment Decisions
All Learning Collaborative participants are required to use data on multiple levels. Year 3
clinicians had a 97% completion rate for their monthly Metric data regarding their use of TFCBT, their skill/comfort in TF-CBT, and the supervision they receive. These data are
summarized and reported back in aggregate to agencies within two weeks, and are used at
agency-based TF-CBT team meetings to assess progress, identify needs, and promote
implementation. Year 1 and 2 clinicians maintained an average metric completion rate of 94%.
Clinicians are also required to use client-level symptom measures at pre-treatment, every
three months, and at discharge, with all TF-CBT clients. The compliance rate for client
symptom data is approximately 69% for Year 3 sites and 54% for the Year 1 and Year 2 sites.
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The majority of missing client data is due to follow-up or discharge assessments not being
completed or being completed late. Senior leaders report that they have seen great value in
the use of metric and assessment data by members of the Collaborative, and that the
opportunity to continue to provide and receive summaries of this data is critical to sustaining
their TF-CBT programs. It is also noteworthy that 16 agencies have demonstrated a
commitment to collect, report, and use assessment and metric data following the end of their
training year.
7. Agency Leadership Supportive of Implementation
Each TF-CBT team has 1-2 senior leaders (agency administrators) that participate in all
aspects of the Collaborative. Senior leaders are provided with monthly metric data about their
agency’s progress in implementing TF-CBT, and participate in monthly senior leader
consultation calls. At Learning Sessions, senior leaders participate in breakout sessions to
identify organizational barriers to implementation and to identify strategies to overcome these
obstacles using the Model for Improvement, a quality improvement approach used in the
Learning Collaborative model. Senior leaders provide peer support and problem solving to one
another, which helps facilitate organizational change. Senior leaders report that having
constant contact with a community of other professionals struggling with similar challenges has
been incredibly helpful, and they plan to continue meeting regularly following the end of the
Collaborative year to discuss sustainability of TF-CBT. Additionally, senior leaders from the
first two cohorts continued to have quarterly conference calls to discuss ongoing sustainability
of TF-CBT. Further, senior leaders report that many of the lessons learned from participating in
the TF-CBT Learning Collaborative can be generalized to other practices across their agency,
and that this initiative has led to practice improvements in other programs.
8. Weekly Meetings of Core TF-CBT Team
Every team was required to meet weekly within their agency to discuss TF-CBT cases and to
promote implementation. Each team has continued to have a one-hour weekly meeting
devoted to TF-CBT during the year, and participants report that this has been crucial to
implementation. As of June 2010, Year 3 staff attended an average of 3.7 TF-CBT team
meetings per month, and Year 1 and Year 2 staff attended an average of 2.6 TF-CBT team
meetings per month. All agencies are planning to continue team TF-CBT meetings following
the end of the Collaborative year. As of June 2010, 15 of the 16 agencies continued to
maintain a regular (typically weekly) team meeting dedicated to TF-CBT. The one agency that
did not maintain a regular TF-CBT meeting following the training year planned to do so
beginning in the Fall of 2010.
9. Sustainability of TF-CBT
Senior leaders at all of the Year 3 agencies report that their agency will continue providing TFCBT following the end of the Learning Collaborative. Each agency developed a written
sustainability plan that was presented at the final Learning Session in June 2010. These plans
typically included details on continuing the core team meeting, providing adequate supervision,
maintaining fidelity, training new staff, use of data to measure and drive treatment, and
spreading TF-CBT within the agency.
There is strong evidence to indicate that all but one of the ten Year 1 and Year 2 agencies
have continued to support their TF-CBT teams and to provide TF-CBT to clients. Nine of these
ten agencies continue to report metric data (the one remaining agency plans to resume in Fall
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2010), and metrics indicate that these agencies continue to assess, treat, and complete TFCBT cases. The Coordinating Center will continue to collect assessment and metric data from
each participating agency over the next year to assess whether the practice has been
sustained.
10. Improved Agency Capacity to Adopt and Sustain EBPs
The Learning Collaborative methodology includes training on promoting systems change to
adopt and sustain EBPs. All participants have received training not just on the TF-CBT model,
but also on how to use the Model for Improvement component of the Learning Collaborative to
make practice improvements. Teams have also received training on assessment, the use of
standardized measures, and how to use data to improve treatment. The experience gained by
the TF-CBT core team in these areas can be easily applied to the implementation of new EBPs
by each agency. In addition, pre- and post- training year assessments of the staff trained in
TF-CBT indicate statistically significant increases in their openness to using EBPs generally.
11. Developing a Network of TF-CBT sites in Connecticut
Participants from all three cohorts have worked together at in-person Learning Sessions, on
monthly consultation calls, and on the TF-CBT intranet site. Staff from all 16 agencies met
together at the annual statewide conference and through the TF-CBT Fellowship program,
which utilized veteran clinicians to assist with training of and consultation to the Year 3 sites.
The Learning Collaborative methodology promotes interaction between sites, and agencies
have shared ideas, successes, and lessons learned with each other throughout the initiative.
Staff also learn from peers in similar roles at other agencies through monthly role-specific
consultation calls and breakouts at the Learning Sessions. Senior leaders from all cohorts
have developed plans to continue regular contact with each other following the end of the
Learning Collaborative year in order to continue development of a TF-CBT network in
Connecticut.
12. Building Capacity of TF-CBT Experts and Champions in CT
The 49 Learning Collaborative staff from the six Year 3 agencies have all received extensive
training on TF-CBT over the course of the year. Within this group, a number of “champions” of
TF-CBT (those who have seen many cases and are promoting TF-CBT within and outside of
their agency) have emerged. These champions will continue to be an important component of
each agency’s sustainability plan and will contribute to Connecticut’s pool of experienced TFCBT clinicians. In addition, the Faculty have continued to provide a TF-CBT Fellowship
program to further build capacity of TF-CBT experts with Connecticut agencies. The
Fellowship provided an additional year of training on TF-CBT and the Learning Collaborative
methodology during Year 3 to three clinicians who excelled in the Learning Collaborative.
Three additional Fellows at different agencies were trained in the prior year.
13. Caregiver Involvement in Treatment
TF-CBT includes caregiver involvement in every session of treatment when a caregiver is
willing and able to participate in a supportive manner. As of June 2010, approximately 53% of
all client visits included at least 15 minutes of caregiver involvement through caregiver
sessions or conjoint sessions for Year 3 sites (59% for Year 1 and Year 2 sites during this
year). When a caregiver was not involved in treatment, clinicians typically report that there was
no caregiver willing and able to participate effectively or that the child did not want a caregiver
to participate.
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14. Consumer Involvement in all Aspects of Implementation
The Learning Collaborative includes a faculty family partner member and each agency had a
family partner participate on their TF-CBT team. The family partners had a dedicated track at
each Learning Session, where they share ideas about their role and receive additional training
from the faculty family partner. The family partner track has been developed in collaboration
with Jan Markiewicz at the National Center for Child Traumatic Stress at Duke University. This
year, family partners contributed to their teams in a variety of ways, including working with their
team to enhance TF-CBT using feedback from the caregiver and child’s perspective,
developing a TF-CBT brochure in partnership with the team, and presenting at Learning
Sessions and the annual conference about how TF-CBT is received by caregivers.
15. Positive Child Outcomes
Preliminary analysis of child outcome measures indicates that children completing TF-CBT
through Learning Collaborative agencies show clinically significant improvements. Specifically,
analysis of the first 190 children completing TF-CBT who received pre- and post-treatment
assessments showed the following:
•
•
•
•
•
43% reduction in child-reported PTSD symptoms
29% reduction in parent-reported PTSD symptoms
55% reduction in child-reported depression symptoms
50% reduction in parent-reported depression symptoms
High caregiver satisfaction rates with treatment
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CHALLENGES & BARRIERS TO IMPLEMENTATION
Changing clinical practice and organizational procedures is inherently challenging. The
Learning Collaborative methodology was developed to address many of these barriers to
implementation by providing a year-long training process, engaging all levels of staff, and
including training on implementation and sustainability. While this initiative continued to be
successful by all accounts, several challenges to implementation and sustainability of TF-CBT
remain:
Family Partner Role
As one of the first Learning Collaboratives to utilize a family partner role, the Coordinating
Center continued to learn from and modify this track over the course of this initiative. The role
definition and training for family partners was enhanced and there appeared to be an improved
understanding among faculty, providers, and family partners about what the position entailed.
Despite the improved clarity of the role and modifications to the family partner training, this
position has still presented challenges. Most agencies continued to have difficulty identifying
and recruiting family partners who could commit to participation because of work or child care
demands. While each agency did ultimately identify a family partner, family partner
participation and attendance varied across agencies. Several family partners who originally
agreed to participate had to subsequently limit or stop their involvement because of family or
work demands. One agency had two consecutive family partners agree to participate and then
have to withdraw.
However, there were several successful family partner collaborations, including one who
worked extensively with the team to enhance their services for sexual abuse and trauma
victims from intake through discharge. This family partner also presented at the annual TFCBT conference and has become involved in other advocacy initiatives in the state. However,
actively engaging the family partners in the Learning Collaborative was perhaps one of the
most challenging aspects of this initiative.
Staff Turnover
Staff turnover during and following the training year continues to be a barrier to sustaining TFCBT. Agencies have generally been able to manage moderate turnover by having experienced
TF-CBT staff continue to train new staff internally. The Learning Collaborative approach, which
embeds TF-CBT within a team, has appeared to be an important element to the sustained use
of TF-CBT thus far. For example, despite the fact that only approximately 40% of the active
TF-CBT clinicians as of June 2010 had completed the Learning Collaborative training (the
remainder have joined their team subsequent to the Learning Collaborative), nearly all
agencies have continued to maintain and grow their TF-CBT programs. This indicates that the
core team’s knowledge of TF-CBT has remained despite turnover.
However, when multiple key team members leave in close succession (which has happened to
several agencies), it has proven difficult to sustain enough expertise to maintain adequate
capacity for providing TF-CBT. Agencies report that outside of their own staff and training
provided by the coordinating center, their new team members are rarely able to attend an
introduction to TF-CBT training due to the high costs of those trainings. For this reason,
providing introductory trainings on at least an annual basis may be necessary in the future in
order to successfully sustain the model.
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Telephone Consultation Calls
Monthly consultation calls were provided separately for clinicians, supervisors, and senior
leaders. Modifications to the consultation calls for clinicians were made based on feedback
from prior years, including reducing the number of participants on calls and providing
consultation on a number of questions and cases submitted prior to each call rather than
focusing on a single case. Faculty also incorporated feedback about providing more direct and
concise answers to questions on the calls, which staff seemed to prefer. Evaluations of the
calls indicated that staff found them more helpful than calls in prior years, but that some staff
continued to be frustrated with the calls. Part of this frustration is because of the call format,
which makes it difficult to know who is attending, what others are doing, and how people are
feeling about what is said (e.g. inability to read facial expressions, body language, etc.).
Lack of Organizational Support
Support from agency leadership among the six agencies in Year 3 was generally strong, but in
at least one agency a lack of support appeared to hamper implementation progress throughout
the year. For example, one agency lacked a senior leader who attended learning sessions,
senior leader breakouts, and senior leader consultation calls, despite multiple efforts by the
faculty to engage this person in the Learning Collaborative. This resulted in what was initially a
motivated TF-CBT team becoming frustrated when they did not feel supported by their
administration in the implementation of TF-CBT. Subsequently, this agency has continued to
struggle to identify potential TF-CBT cases and has provided TF-CBT to comparatively few
children. However, a lack of administrative support was the exception rather than the rule
among Year 3 sites. At most agencies, clinicians reported feeling supported by their
administrators and were provided with adequate resources to learn and practice TF-CBT with
fidelity.
Administrative support continued to appear strong at most of the ten Year 1 and Year 2 sites.
Senior leaders from many of these sites participated in quarterly senior leader conference
calls, attended the annual conference, and participated actively in their agency’s TF-CBT team
meetings. Site visits were conducted with nearly all of the previous agencies, and showed that
while most senior leaders appeared informed about and aware of their TF-CBT team’s
progress and challenges, there were several agencies where senior leaders were less involved
with the program.
Fidelity Monitoring
Monitoring treatment fidelity in a statewide implementation consisting of hundreds of clinicians
and over 1,000 children has been a significant challenge. Fidelity has been assessed through
self-reported metric data by clinicians, which has generally shown that clinicians report using
the TF-CBT components and that treatment length and caregiver involvement are consistent
with TF-CBT guidelines. However, self-reported measures of fidelity are generally not highly
correlated with independent ratings. Community mental health agencies do not typically have
the facilities or resources for live or video observation, and some agencies do not have an
internal supervisor who is experienced enough with TF-CBT to accurately assess fidelity.
There is not yet a national TF-CBT certification program that clinicians can complete to assess
whether they are using the model with fidelity. Further, there is not a validated TF-CBT fidelity
measure currently available. Despite these challenges, the positive outcomes seen among
children who complete TF-CBT suggest that, at least among the clinicians who have
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completed treatment with children, treatment fidelity is adequate.
Need for Ongoing Support
The greatest barrier to sustainability of TF-CBT at the 16 agencies, according to senior leaders
and the Learning Collaborative faculty, is the need for long-term support for training, data
support, and quality improvement. The most frequently asked question among staff has
consistently been about the availability of ongoing support from the coordinating center
following the end of the training year. The first ten agencies who participated in Years 1 and 2
appear to be sustaining their TF-CBT programs and have cited the limited support from the
coordinating center following their training year as being critical to the sustainability of their TFCBT programs.
The specific ongoing support that is most often requested by staff and senior leaders is:
•
•
•
•
•
•
Annual TF-CBT conference where there are opportunities for training for new and
existing team members, and to maintain enthusiasm for TF-CBT
Opportunity for intensive introductory TF-CBT training for new team members
Monthly metric reporting
Support for web-based scoring of client data
Maintenance of the TF-CBT intranet site
Opportunities to receive faculty consultation and support
Fortunately, DCF has thus far provided funding support for these training and quality
improvement services for FY2011 (July 2010 through June 2011) through the use of federal
mental health block grant funds. DCF is also pursuing funds for FY2012. The level of funding
required to sustain the initiative is $53,198 in FY2011, which supports training, a conference,
data reporting, and technical assistance for all 16 agencies ($3324 per agency per year).
However, a long-term solution for continuing to provide these services should be identified.
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SUCCESSES
The third year of the Learning Collaborative has seen many successes. Feedback continues to
show that staff remain enthusiastic and excited about the TF-CBT model and about the
Learning Collaborative methodology. Staff report feeling supported by the coordinating center
and faculty in using assessments, identifying appropriate cases, and using the TF-CBT model.
Supervisors have recognized the importance of identifying ways to monitor treatment fidelity
among clinicians they supervise. Administrators have commented that this initiative has
improved their staff’s ability to use assessment measures and data effectively and has
prompted organizational shifts towards adopting evidence-based practices. Several specific
areas of success are detailed below:
Access to Evidence-Based Treatment
Through this initiative, children and families have access to TF-CBT through 180 clinicians at
16 community mental health agencies across Connecticut. Every child in Connecticut is less
than 60 minutes away from a TF-CBT provider. Children in all of Connecticut’s largest urban
areas, who are at increased risk of trauma exposure and traumatic stress symptoms, have
access to a TF-CBT provider less than 30 minutes away.
Children and Families Served
As of June 2010, 985 children and families have received TF-CBT through the Learning
Collaborative. This represents a significant increase since August 2007, when only one of the
16 participating agencies was providing TF-CBT. The number of children receiving TF-CBT
continues to increase over time.
TF-CBT Team Cohesion
Participants frequently commented that one of the most helpful aspects of the Learning
Collaborative was embedding the TF-CBT team within the agency and carving out a dedicated
weekly team meeting time. This process provided greater team cohesion and support, a team
effort to make progress on implementation, time for clinicians to discuss their cases and the
treatment model with peers, and improved morale.
Sustainability
The number of children receiving TF-CBT statewide continues to increase over time. All six of
the Year 3 agencies reported detailed plans for sustaining TF-CBT at the final Learning
Session in June 2010, which included continuing their weekly TF-CBT meetings and
supervision, using standardized assessments, and reporting metric data. Nine of the ten Year
1 and Year 2 agencies continued to provide TF-CBT and to maintain active teams during the
past year, although there was significant variability among agencies in the size of the teams
and the number of TF-CBT clients seen (the tenth team planned to resume its TF-CBT
program in the Fall of 2010). It is especially notable that the Year 1 and Year 2 agencies
continue to use standardized assessments and to report monthly metric data to assess
progress and outcomes (again, with some variability in rates of compliance). Despite staff
turnover, each of the agencies has maintained, and often expanded, their teams by adding and
training new clinicians using the expertise of their existing team members and through the
statewide TF-CBT conference.
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Statewide TF-CBT Conference
The second annual Connecticut TF-CBT conference held on April 29, 2010 was attended by
over 150 Learning Collaborative alumni, current participants, new TF-CBT team members,
family partners, DCF staff, and others affiliated with the initiative. The conference provided
introductory TF-CBT workshops for new team members and those without significant
experience, advanced TF-CBT trainings for experienced clinicians, and a number of sessions
on TF-CBT innovations and adaptations that were led by Learning Collaborative participants.
DCF staff and TF-CBT clinicians jointly presented a panel discussion and case study on
collaboration between child welfare staff and TF-CBT providers. The conference also provided
DCF staff who attended with knowledge about trauma-focused treatment and opportunities to
meet and collaborate with TF-CBT providers. Qualitative and quantitative feedback from the
conference was overwhelmingly positive, and many participants stated that it renewed
enthusiasm and excitement on their TF-CBT teams.
TF-CBT Fellowship Program
The second year of the TF-CBT Fellowship program provided training to three experienced
clinicians at three different agencies who completed the Learning Collaborative training. The
Fellows participated as co-trainers at learning sessions and on conference calls for the Year 3
agencies, were each paired with one site to provide guidance and support, and received
advanced training from the faculty in how to train staff using Learning Collaborative principles.
The three Fellows reported that the experience was rewarding for them personally in terms of
enhancing their TF-CBT and training skills. Administrators from each agency represented by a
Fellow stated that it was helpful to have continued connections with the faculty and to have a
staff member receive advanced training to build capacity within the agency.
Use of Data
Agencies continued to report that a significant change in how data are used has occurred
among many staff. Data from assessment measures have become increasingly viewed as an
important component of treatment. Data from monthly metrics continue to be used by
supervisors and administrators at most agencies to support and sustain the implementation the
TF-CBT program. For example, aggregate self-report clinician competency ratings on the TFCBT components are used by agencies to focus supervision and team trainings on skills with
which clinicians are less comfortable. Similarly, administrators have used monthly data about
agency-wide screening for trauma and the number of TF-CBT cases seen to make changes to
intake screening procedures and to add additional TF-CBT clinicians to the team to build
capacity. DCF’s support for the Coordinating Center to continue collecting and reporting
monthly metric data for Year 2 and Year 3 agencies has been instrumental to the sustainability
of their programs.
Development of Data Systems
The data management systems for both measures and metrics were modified and enhanced in
Year 3 and have continued to facilitate the use of standardized measurements with clients and
the rapid turnaround of results to clinicians and agencies. The online data management
systems are easy and quick for clinicians and coordinators to use and allow for real-time
monitoring by the Coordinating Center. Missing or incorrect data can be identified and tracked
by the Coordinating Center.
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Dedicated TF-CBT Team Coordinators
The selection of a designated TF-CBT team coordinator at each agency (8 hours/week) has
improved implementation in multiple ways. Each coordinator functioned as a liaison between
their agency and the coordinating center, and was able to discuss implementation progress
and receive technical assistance weekly with the coordinating center staff. Each coordinator
also facilitated implementation by planning and running the agency’s weekly TF-CBT team
meeting and keeping the team focused on TF-CBT during Action Periods. Coordinators
managed their agency’s TF-CBT data, including entering and scoring client assessments and
providing feedback reports to clinicians. A designated coordinator reduced confusion about
who was responsible for what, provided a clear communication path between each agency and
the coordinating center, and helped organize and focus the team on TF-CBT. The coordinating
center and faculty were able to regularly assess each agency’s progress and challenges and
provided technical assistance to individual sites and training to all sites based upon this
feedback. In many cases, this allowed problems, challenges, or misunderstandings (e.g.
about the TF-CBT model, assessments, or the Learning Collaborative requirements) to be
identified early and corrected before they became widespread.
Satisfaction
Agency staff have been surveyed about their satisfaction with each Learning Session and also
participated in a focus group at the end of the training year. Qualitative feedback from agency
staff, DCF staff, and others involved in the initiative has been generally very positive. For
example, one clinician stated in the focus group that “We have had really favorable results with
the treatment model, and in a push for short-term treatment, this really fits well.” Families who
have received TF-CBT have also expressed high levels of satisfaction with their treatment.
Intranet
The TF-CBT Learning Collaborative intranet site developed by the coordinating center for this
initiative has been essential for disseminating information to participants and for participants to
share innovations and ask questions. The intranet continues to be used by participants, and
has generated a number of thoughtful and complex clinical and organizational questions from
staff. The site has also proven to be an efficient method of sharing information (e.g. clinical
measures, consultation call schedules, training requirements) with all participants. Staff
reported in focus groups that the responses they received to questions on the intranet site
were incredibly detailed and helpful to their provision of TF-CBT. Finally, the intranet site is an
important link between staff participating in cohorts because the site allows collaboration and
interaction between all current and former participants. There was, however, a decline in
questions posted to the intranet site towards the end of the training year.
Champions and Cheerleaders
Supporting the identification of "champions and cheerleaders" for TF-CBT at each agency has
been an important step for facilitating implementation and planning for sustainability. Greater
attention was paid by the faculty to identify champions earlier in the year and to work with
senior leadership to identify and utilize the enthusiasm of champions within their agencies.
Champions within three agencies (and statewide) were further cultivated through the TF-CBT
Fellowship program. In addition, champions were utilized as co-trainers at several DCF area
office presentations on TF-CBT to educate DCF staff about the treatment and referral process,
and to connect them with a contact person on the TF-CBT team.
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Buy-in at All Levels
The Learning Collaborative method of including clinicians, supervisors, senior leaders, and
family partners in all aspects of the initiative has resulted in increased buy-in for adopting TFCBT. Clinicians and supervisors understand the appeal of a manualized treatment that
incorporates many of their current clinical skills, and became more enthusiastic when they saw
the positive client outcomes among their initial treatment cases. Administrators appreciate the
strong empirical support of the model and value time-limited treatment as a method of
improving overall agency capacity. Administrators have also valued the use of data to measure
treatment progress and to assess the TF-CBT team's performance over time. Buy-in at the
highest levels of an agency is important for successfully changing organizational policies,
procedures, or informal norms that can be barriers to implementation of TF-CBT or other
evidence-based practices. Finally, the team-based Learning Collaborative approach to training
has improved morale within many agencies. Staff reported that they became closer through
their Learning Collaborative work, attendance at the interactive trainings, and through their
agency-based weekly meetings. This support from colleagues is doubly important when
working with traumatized clients because of the increased incidence of vicarious trauma and
burnout among staff treating traumatized children.
Family Partner
The family partner track was further improved in Year 3, including a full day training for family
partners and site coordinators and additional consultation with agencies about how to utilize
the family partner on their team. Redefining the role from “family advocate” (in Year 1) to
“family partner” continued to help clarify the role, which was to be a consumer advisor to the
team rather than an advocate for individual families. In Year 3, family partners advised their
teams about clinic procedures and the experience of receiving TF-CBT from the consumer
perspective, assisted with the development of a TF-CBT brochure, and presented the
consumer perspective at Learning Sessions and at the annual conference. Ongoing
consultation with Duke University was maintained between the coordinating center and the
faculty family partner for the development of this track.
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CONCLUSIONS
The Connecticut TF-CBT Learning Collaborative has, by virtually all indicators, been
successful at making the evidence-based practice of TF-CBT available to Connecticut’s
children and families. All of the 16 participating community mental health agencies continue to
maintain active TF-CBT teams, albeit with some variation in caseload, number of staff trained,
and experience. These findings are especially significant given the multiple demands placed
on agency staff, the additional time required to utilize an EBP, and the high rate of staff
turnover.
However, given these challenges, as well as funding and productivity issues faced by
community clinics and the current bleak economic climate, there continue to be significant
threats to long-term sustainability of the TF-CBT programs. For example, competing demands
in the absence of continued accountability or support for TF-CBT continue to threaten
sustainability. Thus, a minimal amount of ongoing quality assurance and training is strongly
recommended to support the significant investment in TF-CBT programs that DCF and
participating agencies have made over the past three years.
In addition, the Learning Collaborative methodology addresses barriers to implementation
through an innovative and, based upon these results and those from other initiatives using the
methodology, a highly effective approach to training. A Learning Collaborative may require
additional startup time, money, expertise, and support than traditional forms of training, but the
outcomes are exponentially greater and the costs for ongoing training are likely to be
significantly less. A Learning Collaborative equips agencies to sustain use of EBPs, to
efficiently use data to drive treatment and document outcomes, and to improve supervision
procedures. This emphasis on organizational change is not only critical to the sustainability of
an EBP, but builds capacity for an agency to adopt other EBPs and to improve practice
agency-wide. Thus, the Learning Collaborative model should also be considered for other
implementation, dissemination, and training initiatives.
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RECOMMENDATIONS
Based upon the qualitative and quantitative data from the first three years of the Connecticut
TF-CBT Learning Collaborative, the following recommendations are made:
1. Data should be used systematically for quality improvement. In order to support
the sustained use of TF-CBT by these agencies, it is recommended that ongoing data
reporting of monthly metrics and scoring of client assessment measures is supported at
a statewide level. Continued data support would allow agencies to continue using data
for quality improvement, would provide a transparent method for agencies to maintain a
focus on sustaining TF-CBT, and would allow for evaluation of the long-term
effectiveness of the TF-CBT implementation.
2. A statewide conference for all TF-CBT Learning Collaborative providers should
continue to be held annually. To further strengthen Connecticut’s capacity of TF-CBT
experts and champions, and to promote ongoing sustainability of the model, the annual
statewide TF-CBT conference should continue to be held for all current and former TFCBT Learning Collaborative members. Continuation of the annual conference would
provide advanced training for experienced clinicians, basic training for new clinicians,
and opportunities for Learning Collaborative members to continue sharing innovations
and strategies with staff from other agencies. A TF-CBT conference could also
contribute to building a trauma-informed system of care in the state.
3. Introductory TF-CBT training should be routinely provided for new TF-CBT staff.
Staff turnover is relatively high in outpatient community mental health agencies, and
new staff must be trained to provide TF-CBT. The TF-CBT developers recommend that
staff new to TF-CBT should receive at least a 2-3 day Introduction to TF-CBT Training,
provided by a TF-CBT Train-the-Trainer, followed by ongoing supervision and
consultation. Thus, it is strongly recommended that this introductory training be offered
to all new TF-CBT staff at least annually. Staff receiving this training should be
committed to providing TF-CBT to at least three children and families within one month
of the training.
4. The Connecticut TF-CBT intranet should be maintained and sustained.
Maintenance and development of the TF-CBT Learning Collaborative website should be
continued to provide access to resources and clinical materials for all staff, including
resources specific to the Connecticut TF-CBT Learning Collaborative. This would also
foster communication between agencies by providing a forum to ask questions and
share innovations across the Collaborative. It is recommended that a TF-CBT trainer be
available for 2-3 hours per month to respond to discussion board questions and provide
consultation through the intranet site, or through “drop-in” consultation calls.
5. Ongoing site-based technical assistance should be available as needed. Sitebased technical assistance should be provided when an agency requests support
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around a particular issue or when their data suggests that they are struggling to sustain
TF-CBT. Site-based consultation could be provided in person or over the telephone as
needed.
6. TF-CBT should continue to be marketed to DCF Staff and other community
stakeholders (including raising awareness about access and the referral
process). There is currently additional capacity to provide TF-CBT at most of the 16
agencies. The sooner children are evaluated and treated following a traumatic event,
the better the prognosis. DCF should continue to train all new staff hires in the Child
Welfare Trauma Training Toolkit, offer specialized trauma trainings, and continue its
efforts to educate staff at local office meetings about TF-CBT and how to make referrals
for treatment.
7. Use of TF-CBT and other EBPs should be incentivized. It is strongly recommended
that state and federal policies provide adequate support and incentives for agencies that
use EBPs. Sustaining an EBP with fidelity requires resources for ongoing training,
adequate supervision, use and interpretation of data, and time for team meetings. Many
agencies face financial challenges that force them to choose between providing these
resources or re-directing staff time to seeing more clients. External incentives for using
EBPs would improve the adoption and sustainability of EBPs. Enhanced reimbursement
rates for the use of TF-CBT and other EBPs would be a significant incentive.
8. Fidelity to the TF-CBT model should be closely monitored. Monitoring treatment
fidelity for hundreds of clinicians across 16 agencies is challenging, especially given the
lack of a validated self-report TF-CBT treatment fidelity measure. It is recommended
that the existing treatment fidelity monitoring systems using monthly self-report metric
data be continued, as they indicate that clinicians report maintaining fidelity and that the
children they have treated have improved outcomes. If and when incentives to provide
EBPs exist, it is also recommended that additional, non self-report fidelity methods be
utilized in order to provide a more objective assessment of fidelity. These methods
would need to be efficient and minimize the burden on staff, and should only be
considered if and when incentives for EBP use exist because of the considerable time
they will likely take to implement. Some examples of additional fidelity monitoring
include periodic case consultation calls with expert trainers, coding audio or video tapes
of a small percentage of sessions, supervisor ratings, and/or a questionnaire completed
by the child or caregiver.
9. Capacity for delivery of TF-CBT should continue to grow and expand. Given that
outpatient clinics who are routinely screening for trauma exposure report that 60-80% of
children seeking services screen positive for exposure to a traumatic event, the access
to TF-CBT should continue to be expanded. Services should be expanded in the
existing 16 agencies and opportunities should be explored to disseminate the model to
other provider organizations geographically distributed across the state. In addition,
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access to TF-CBT should be explored in other populations such as residential
treatment, foster care and juvenile justice populations.
10. The Learning Collaborative model should be considered for other
implementation, dissemination, and training initiatives. Qualitative and quantitative
evaluations strongly support the effectiveness of the Learning Collaborative for
implementing and sustaining TF-CBT in Connecticut. Many staff identified the shared
learning environment and cross-site networking, use of assessment and metric data,
interactive training, and training tracks for staff in multiple roles as being as important
elements for the sustained use of TF-CBT. Thus, it is recommended that the Learning
Collaborative methodology be utilized to disseminate other evidence-based or
promising practices, as the available evidence from this and other initiatives suggests it
is more effective at creating sustainable change than traditional training approaches.
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6-MONTH FOLLOW-UP ADDENDUM
As of December 2010, all 16 agencies continue to provide TF-CBT. These agencies
cumulatively had 165 clinicians, 19 supervisors, and 17 senior leaders active on their TF-CBT
teams. This represents a 12% increase in active TF-CBT staff since June 2010. Administrators
report that this increase was due in large part to the two day Introduction to TF-CBT training
provided through this initiative in December 2010, which was attended by 70 new clinicians
and supervisors.
All 16 agencies continue to submit and receive monthly TF-CBT metric data and continue to
use standardized assessments with their TF-CBT clients (the one agency that had stopped
submitting metrics because of participation in the NCTSN Core Data Set resumed doing so in
October 2010).
There continues to be variability in the number of children served by each agency, with some
agencies serving as few as 6-8 clients per month and others serving 35-40 per month.
However, the cumulative number of children receiving TF-CBT monthly (338 as of December
2010) continues to increase as shown below. Thus, six months following the end of the
Learning Collaborative, all 16 agencies continue to maintain (and often, grow) their TF-CBT
programs and the number of children served.
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Appendix 1: Sample Data from the Scoring Program for Client Measures
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Appendix 2: Sample Metric Summary
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