Success Cycles, or
from Kick the CANS to Yes, We CAN!
Nathaniel Israel, PhD
May 16, 2011
SFDPH OQM for CYF-SOC
Disclaimer
• The work presented here by an employee
of the San Francisco Department of Public
Health does not imply endorsement by, or
the official position of, the San Francisco
Department of Public Health.
Thank-yous
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Sai-Ling Chan-Sew
John Lyons
Parent (and now Youth!) Partners
Stephanie Romney
Deborah Sherwood
Emily Gerber
….and all of our system partners who
make this work meaningful for families
Implementation Development:
CANS
• Lyons (2008) states that implementation of the CANS
proceeds through distinct stages in how people perceive
and use it. They are as:
• a Form
• a Tool
• the Work itself
• Only in the second and third stages do families and
clinicians see clear benefits in using the CANS to
collaboratively identify, set and achieve goals
• Implementation must focus on scaling-up use while also
increasing people’s ability to use the CANS as a
collaborative communication and decision-support
framework
Going to Scale
• Success with a pilot does not mean that
system-level roll out will be successful
• The complexity becomes geometric when
scaling up
• Paradox: may have a larger total
investment with worse outcomes
Paradox Explained
• Unless clinicians get to the point at which they
use the CANS as a natural part of their clinical
practice, the CANS will seem like just another
form....in which case you’ve invested a lot of
time and effort to get pushback
• Similar process with becoming proficient in
nearly any endeavor: you start with frustration
and failure, and then gradually over time you
become effortlessly proficient (figure skating
(triple axle, triple lutz, football: perfect spiral)
CANS Implementation Dynamics
• Form  Pushback
– “I thought we were trying to reduce the
paperwork in the system”
• Tool  Trade Time Invested for a Clear
Return
– “It’s more work, but I can see why we do it”
• the Work  Part of Routine / Clinical Flow
– “It’s just the way I think now”
Getting Stuck at Step 1
• I already ask about these things; why isn’t
narrative good enough?
– Stories and experiences lost if they’re not
tracked; no chance to have larger effect
– How do we know what should be a client,
program, system priority?
• You can’t ask families about these things
without alienating them
– Families: it’s not what you ask, but the way
you ask it which matters
Getting to Step 3
Fundamental shift for many clinicians
• Realize that Training for Collaborative
Decision-Making is often distinct from our
professional training / identity
– Requires a humility that is rarely taught or
valued: taught to interpret and be experts
– Requires us to be willing to be taught and led
by our families: to share power
• Requires new emotional experience and
new skills
Can this wait?
• Nearly half of all clients either are poorlyengaged or prematurely drop out
• 25% of clients get worse while in
treatment
• Leading cause of clinician burnout
• Families’ response to Assessment-asUsual
– “I’m so mad because I’ve just had a CANS done,
and none of this happened. (Working
collaboratively) is how I wanted it to happen.”
Listening to Learn
• Conducted over 20 focus groups with
parents / caregivers of African-American,
Latino and Chinese children and youth
• Latino and Cantonese groups conducted
in native language by native speakers
• Designed to better understand how using
the CANS in the care process can
maximize engagement, family-direction
What we Heard
Parents taught us that Clinicians should be able
to:
1. Explain the Treatment Process on first contact
2. Sensitively assess the seriousness of behavioral /
emotional concerns
3. Clarify the function of identified behavioral /
emotional concerns
4. Collaboratively review the assessment for
accuracy
5. Create clear, achievable goals in the family’s
words
6. Review and problem-solve progress towards goal
achievement
What were we missing?
• Already created forms:
– Embedded CANS into existing narrative
assessment
– Created a Treatment Plan that linked the
CANS items and Treatment Plan Goals
– Feedback system that showed progress over
time
• Clinicians were doing these things without
family engagement / involvement
Training Format
Parents’ goal: to change clinicians’
behavior to be more in line with
collaborative practice
• Curriculum 3 half-day trainings, co-led by
parent. Two role-plays by each person
each day
• At the following training date we discuss at
least one new behavior which clinicians
tried
Skill Example
1: Explain Treatment Process on First
Contact
• “Conversation Starting Point” for
Confidentiality
• Collaborative Scheduling Form
– Content of First Sessions
– Supports / Needs for Attending Sessions
– Immediate Needs / Tips / Behaviors to Try
Skill Example
2. Sensitively assess the seriousness of
behavioral / emotional concern
• Asking parent about Child / Youth
Substance Use
• Typical response
• “The quickest way to hear that there is no
substance use is to directly ask if there is
substance use”
Skill Example
• Alternate method:
– Start with strengths of parent “Many parents
are concerned about the role models their
children are exposed to”
– Ask about situations which are not personal
“Do you have any concern that your youth
sees people in your neighborhood who are
using substances?”
– Move successively closer to personal
information (school and peers, home)
Skill Examples by Cultural Group
• Many similarities across groups
– All stated that all questions associated with
completing the CANS can be asked
• At times, persons of different cultural
groups emphasized different concerns
– African American families particularly
concerned about issues of Confidentiality
– Discussions of sexual behavior particularly
sensitive for our Cantonese parents
Care Empowerment Training
• Outputs:
– Three trainings to date with different
programs; parent partner is co-trainer
• Outcomes:
– Trainee perception of training relevance
– Parent and Youth satisfaction with clinician
skills (currently being collected)
– Client outcomes (variation by parent-rated
skill)
Top Secret Preliminary
Findings
Relevance and Usefulness
Parentdirected
Training
Dimension
Discussion
Relevance
Handout
Usefulness
Exercises’
Relevance
Overall
Relevance
Professionaldirected
4.62
4.40
4.75
4.45
4.75
4.40
4.75
4.45
Summary: Parent Training
• This training is consistent with the goal of more
fully empowering families in their children’s
behavioral healthcare
• It allows us to move collaboration upstream in
the care process, replacing practices which have
led to clinician burnout and client dropout
• It provides specific, family-directed practices
which we can teach and track for how they relate
to engaging families and achieving clients’ goals
Rollout: Next Stage
• Engaging youth in similar process
• Scaling-up: Step 1
– Required training for all incoming interns and
their supervisors
– Using multi-method feedback on change in
care practice (parent and youth survey,
ongoing focus groups)
• Your thoughts and feedback
Resources and Feedback
• Scripts and resources available online at:
http://successfulmentalhealthsystems.wikispaces.com
• E-mail me at: nathaniel.israel@sfdph.org
or (if there’s the issue of attachments)
ndisrael@gmail.com