What it Really Takes to Implement
Evidence-Based Practices in
Community Focused Services
Eleanor Castillo, Ph.D., Corporate Director, Outcomes & Quality Assurance
Lisa Davis, LMFT, Clinical Director
Kathy Cox, LCSW, Ph.D., Clinical Director
Building on Family Strengths Conference
Portland OR
June 01, 2007
1
Overview
I.
Overview
a.
.
b
II.
(Eleanor Castillo, Ph.D.)
EMQ Children & Family Service
Overview of EPB implementation
Implementation of Positive Behavior
Interventions and Supports (PBIS) in
Residential (Lisa Davis, LMFT)
a.
b.
c.
d.
e.
Residential services and population served
Context for change
Overview of change process and changes implemented
PBIS implementation and sustainability strategies
Facilitative factors and challenges
2
Overview
III. Implementation of TF-CBT within Wraparound
(Kathy Cox, LCSW)
a.
b.
c.
d.
IV.
Context for change
Overview of change process and changes implemented
TF-CBT implementation and sustainability strategies
Facilitative factors and challenges
Summary and Questions and Answers
(Eleanor Castillo, Ph.D.)
3
EMQ Mission
To work with children and their families
to transform their lives, build emotional,
social, and familial well-being, and to
transform the systems that serve them.
4
EMQ Children & Family Services

Services in 18 California counties  In Home Family Treatment

Family Partnership Institute

Chemical/Alcohol

Dependency Education &
Prevention

Therapeutic Behavioral
Services (TBS)

School Based Mental
Health Services

Wraparound

FIRST 5 Services

Residential Treatment

Mobile Crisis Intervention


Outpatient
Foster Care-Professional
Parent, ITFC
5
Core Philosophy
Consistent with the Child and Adolescent Service System
Program Principles (CASSP)
• Strengths Based
• Family Centered
• Community Based
• Culturally Competent
• Individualized
• Natural Supports
• Team Based/Collaborative
• Persistence
• Outcome Based
6
Agency-wide # of Youth
July 1, 2006 – March 31, 2007
Crisis
735
Wraparound
495
FFA
443
Day Rehab
29
Outpatient
557
System of Care
171
Addiction Prevention Service
291
First 5
61
TBS
163
School Based
97
Residential
71
Matrix
39
Total
3152
7
Implementing and Sustaining EPB
A.
Agency Culture
1. Infrastructure
a.
b.
Budget
Information Management
i. Electronic health record
ii. Outcomes tracking
iii. Quality improvement
c.
d.
e.
Policy and procedures
Human Resources
i. Job description
ii. Recruiting and Retention
On-going evaluation of process and treatment
8
Implementing and Sustaining EPB
C. Training Structure
1.
2.
3.
4.
Training overview
Coaching and supervision
Consultation (average 18 months)
Boosters
D. Meeting Structures
9
Implementing and Sustaining EPB
E. Agency and Other Collaboration
1. Payors – DCFS, DHM
a. Reduce financial barriers
2. Referral process
3. Engaging families in the implementation process
4. Focus groups with all stakeholders
10
Implementation of Positive Behavioral
Interventions and Supports in
Residential Services
11
Residential Services Description
4 RCL (Rate Classification
Level) 14)




Two units for children ages 6-12
years
Two units for youth ages 12-18
years
3 are co-ed and 1 is all male
Each unit has capacity to serve
up to 10 children
Staff Resources









Clinical Director
Clinical Program Manager
Clinician/Case Manager
Residential Cottage Supervisor
Milieu Activity Therapist
Psychiatrist
Educational Resources
Recreational Therapist
Registered Nurse
12
Residential Array of Services
Comprehensive assessment
of all life domains
 Family Therapy
 Individual Therapy based
on (TF-CBT)
 Psychoeducational and
psychotherapeutic groups
 Intensive case
management and linkage
to community activities
 Nursing and psychiatric
services

Academic support
 Family Finding
 Family Partner Services
 Medical/Dental
Assessment and Linkage
 Recreational, Music and
Art Therapy
 Therapeutic milieu based
on PBIS principles
(universal interventions)

13
Residential Targeted Population
Youth with severe emotional and behavioral challenges
Youth who are experiencing:
 Maladaptive response to trauma
 Typically victim of physical abuse and family
impacted by substance abuse
 Severe impairment in capacity to function in their
daily activities
 Psychotic features or dangerousness to self or other
 Many with co-morbid disorders (primarily mood
disorders and behavioral disorders)
 CAFAS scores at entry over 140
 Average youth profile: English speaking, Hispanic male
between 13-18 years old with more then 3 prior
placements


14
Why Re-design Residential Services?
 To
implement evidence based services including PBIS, and
Trauma Focused CBT
 To utilize residential services as an intervention, not as a
placement
 To achieve improved outcomes
 Increase youth and family connections
 Develop sustainable community supports
 Ensure permanency for youth in a loving, supportive family
 To ensure consistent implementation of a strength based,
needs driven, family centered, individualized and culturally
relevant philosophy in all aspects of care
 To partner with families and ensure family involvement in all
aspects of care
 Maintain families connection with their community and
increase natural supports
15
Change Process





Established a leadership team
Use of change methodology-Implementation
Management Associates (IMA)
 Business Case for Action
 Charter
 Sponsorship contract
Work team approach with inclusive decision making
Well developed communication plan
3 phase change process:
 Gathering data/information
 Implementation
 Evaluation
16
Residential Redesign Work Teams
Phase I Work Plan
Residential Redesign Team
Started 1/3/04
Completed 5/1/05
Questionnaire
Work Team
Larry North
Andrew Pane
Nancy Minister
Simon Purse
Charity Packer
Customer
Survey Work
Team
Marina Boliaris
LEAD
Focus Grps w/
Current Post DC
Youth/Family
Population
Analysis Work
Team
Integration Team
Core Leadership
Team Charter
Development
Best Practice
Conference
Work Team
MAT Focus
Group
Literature
Search E.B.P.
Work Team
Family Inclusion
Work Team
Michelle
McNerney
LEAD
Jeff Reichenthal
LEAD
Jason Glover
CO-LEAD
Lisa Davis
LEAD
Lisa Davis
Simon Purse
LEAD
Lisa Davis
CO-LEAD
Simon Purse
LEAD
Lisa Davis
Andrew Pane
Lanetta Smyth
Larry North
Jason Glover
Lanetta Smyth
Larry North
Jennifer M. Miller
Laura Palmer
Charlotte
Hendricks
Marina Boliaris
Lanetta Smyth
Lisa Wilson
Laura Palmer
Jeff Reichenthal
Roger Bundlie
Jennifer Miller
Lisa Wilson
Jennifer Pitt
Lisa Davis
Jason Glover
Lisa Wilson
Andrew Pane
Lanetta Smyth ?
Tom Burgis
Susannah Folcik
Linda Owens
John Crowder
Amalia Ferriera
Charity Packer
Judy Palen
Jennifer Miller
Janet Atkins
DFCS
Chris Mullins
Cheryl Sanwo
Veronica Padilla
Michelle
McNerney
John Crowder
Al Miranen
DFCS
Connie Wright
Andrew Pane
CO-LEAD
Chris Mullins
John Crowder
Michelle
McNerney
Sherrie Tullsen
Michelle
McNerney
Simon Purse
Cheryl Sanwo
Nancy Minister
Charity Packer
Charlotte
Hendricks
Jennifer Best
Connie Wright
Jennifer Miller
Craig Wolfe?
17
Residential Redesign Work Teams
Residential Redesign
Implementation Work Plan
Phase II
Completed 8/06
Program
Procedures
Andrew Pane
LEAD
Tom Burgis
Connie Wright
Laura Palmer
Charity Packer
Visitation Work
Team
Family Event
Planning Team
EBP Work Team
Family Finding
Chris Mullins
LEAD
Connie Wright
CO-LEAD
Lisa Davis
LEAD
Lisa Davis
LEAD
Andrew Pane
CO-LEAD
Andrew Pane
Chris Mullins
Teresa Barstow
Laura Palmer
Andrew Pane
Bobby Dehn
Michelle
McNerney
Roger Bundlie
Nancy Minister
Lanetta Smyth
Monica Martin
F.S/Sequoia
Tom Burgis
Penn East MAT
Linda Owens
Core Leadership
Team Charter
Development
Publish/Present
Redesign
Jason Glover
LEAD
Lisa Davis
LEAD
Lisa Davis
CO-LEAD
Lisa Davis
Larry North
Eleanor Castillo
CO-LEAD
Laura Palmer
Lisa Wilson
Veronica Padilla
Andrew Pane
Jason Glover
Carl Sumi
Tanisha Clarke
Michelle
McNerney
Lanetta Smyth
Lanetta Smyth
Laura Palmer
Jennifer Wilson
Clinician
Connie Wright
Connie Wright
Susannah Folik
M.H. Pilot
John Crowder
Tanisha Clarke
Veronica Padilla
Lisa Wilson
Rodney Tabares
Eleanor Castillo
Laura Palmer
Monica Martin
Larry North
Jessica Weiler
Jon Oakes
Sherrie Tullsen
Carl Sumi
18
Residential Redesign Work Teams
Residential Redesign
Implementation Work Plan
Phase III
In Progress
PBIS Support
Team
Jon Oakes
Tim Cregor
Program
Procedures
Family Inclusion
Practices
PBIS
Sustainability
Family Finding
Tom Burgis
Carly Mitchell
CO-LEAD
Michelle
McNerney
LEAD
Lisa Wilson
LEAD
Connie Wright
Monica Renn
Laura Palmer
Michelle
McNerney
Larry North
Connie Wright
Janet Banks
Charity Packer
Maryann Waddel
Carl Sumi
Consultant
Bobby Dehn
Lead ?
Terri Barstow
Michelle
McNernery
Tanisha Clarke
Jason Glover
Jessica Weiler
Jon Oakes
Larry North
(Consultant)
Laura Palmer
CO-LEAD
Lisa Wilson
Summer Castro
Tanisha Clarke
Terri Barstow
TF-CBT
Charity Packer
John Crowder
Rodney Tabares
Lisa Davis
LEAD
Chris Mullins
Lisa Davis
Consultant
Jeff Meduri
Core Leadership
Team Charter
Development
Carl Sumi
Consultant
Michelle
McNerney
Laura Palmer
Orly Abta
Tim Cregor
Laura Palmer
Caroline Devaney
Amalia Ferria
Jon Oakes
Alicia Martinez
Veronica Padilla
Consultant
Elisa Navarini
Erin Takagishi
Jennifer Wilson
Willow MAT
Chris Mullins
Bobby Dehn
Jenner Petrello
Dennis Bigalk
Rodney Tabares
Jason Glover
Lisa Wilson
Larry North
Consultant
Mariann Waddel
Roger Bundlie
19
Why PBIS?





Evidence in schools that approach creates pro social
positive environments
Alignment with agency philosophy
Goodness of fit: congruent with behavioral approach
already utilized
Focus on increasing quality of life, achieving broad goals
and supporting portable skills
Use of a proactive and educative approach to support
elimination of “control based” interventions including
restraints
Eber, Sugai, Smith, & Scott (2002); Scott & Eber (2003)
20
PBIS Implementation Strategies
Training Model
Booster
Training
Developed internal
training capacity
Consultation
Overview
Extensive Training on FBA, BSP
Support Team and
Team Meetings– FBA,
BSP
Operations Team
system changes
3 - 8 hour
trainings for 60
staff
21
PBIS Implementation Strategies







Develop behavior and cottage management system
Establish core values/expectations and settings
Reviewed past point and level system, develop new
systems based on values matrix
Goal to enter points into agency’s electronic record
for easy data analysis
Provide consultation and problem solve barriers
Develop and adapt all program policies and
procedures to reflect PBIS implementation
Develop procedure on how to incorporate into
documentation (i.e., assessment, Tx plan, etc.)
• Need to coordinate with Medi-cal and CCL
regulations.
22
PBIS Implementation Strategies

Supervision practices changed

Clinical supervisors review F.B.A. and B.S.P. in individual
supervision and group supervision

Time in weekly team meeting set aside to delegate
tasks to complete F.B.A. and B.S.P.

PBIS support team participates in “team meetings”
monthly; put forms on the Intranet

New tasks built into staff evaluation, program goals,
and interview process
23
Facilitative Factors for the
Implementation of PBIS in Residential

Agency and PBIS philosophy alignment

Outcome and evaluations department

Data management practices

Use of change methodology and quality improvement
techniques

Trainer/consultant thoroughly learned operations, built
relationship with staff

On going support from consultant

Sponsorship and resources from management
24
Facilitative Factors for the
Implementation of PBIS in Residential

Structuring discussions of F.B.A. and B.S.P. in team
meetings and clearly delegating tasks and timelines

Development of a “Support Team” and an Operations
work team

Key staffs’ skill sets and enthusiasm

Being open to concerns and seeing resistance as helping
to inform the change process

Building PBIS job expectations into staff evaluations

Acknowledging staff and celebrating successes
25
Challenges

Implementing significant change while caring for children
24-7

Deciding what practices to discontinue

Implementation of a sustainability plan

Considering multi-systemic needs and regulations

Learning curve on how to utilizing data to inform practice

Establishing consistency and accountability across three
shifts

Agency culture “flavor of the day”

Developing internal training capacity
26
Wraparound as a Philosophy
(VanDenBerg & Grealish, 1996)
 Strength-based
 Needs
driven
 Family-centered
 Provider as family partner versus “expert”
 Team works collaboratively to reach goals
27
Trauma-Focused Cognitive Behavioral
Therapy as a Treatment Modality





Designed for youth ages 3 to 18 years
Aimed at reducing symptoms related to trauma
Short-term treatment (3 to 4 months)
Includes coping skills training; gradual exposure
and processing of traumatic memories and
reminders; safety skills training.
Individual, caregiver, and joint caregiver-child
sessions.
28
TF-CBT as an
Evidence Based Practice
Randomized Control Trials for Sexually Abused
Children with PTSD systems (Cohen, Deblinger,
& Mannarino, 2004)
Significant reductions (26%) in parental emotional
distress
 Significant reductions in PTSD, depression, behavior
problems in children (63%; 41%; 23%, respectively)
 Percent no longer meeting PTSD criteria at post
treatment:
54%- Client-Centered Therapy
79%- TF-CBT

29
Wraparound Sacramento’s Need
for Trauma Therapy

FY 2005-2006: 71 youth admitted to wraparound
services at EMQ Sacramento

Majority of these youth (64%) were referred by
Child Protective Services

Most prevalent DSM-IV Axis I diagnosis upon
admission: PTSD (23%)
30
Factors Facilitating Wrap &
TF-CBT Integration

Sponsorship by EMQ Administration

On-going Support from TF-CBT Consultant

Outcomes and Evaluation Dept. Support

Staff Enthusiasm

Clinicians’ Willingness to Learn by Doing

Celebration of Successes
31
Challenge: Partnering with Payors &
Referring Agencies

Clarify the role of EMQ Wraparound as a Mental
Health Services provider

Provide evidence of TF-CBT as EBP

Facilitate top-down communication in partnering
agency regarding approval to use TF-CBT within
Wraparound

Utilize CFT process to recruit participants
32
Challenge: Recruiting Therapy
Participants

Developing screening criteria (types of trauma,
substantiated abuse, non-offending caregiver
availability, PTSD symptomalogy).

Describing TF-CBT in non-threatening terms

Using TF-CBT in on-going versus new therapy
cases

Obtaining permission to audio tape sessions
33
Challenge: Resolving Clinician’s
Concerns

Anxiety regarding proficiency level in
TF-CBT

Uneasiness with audio tapping sessions

Need to establish client readiness and
psychological safety prior to beginning trauma
work
34
Challenge: Adopting Evaluation Tools
 Trauma
Sx Checklist (TSCC & TSCYC)
(completed by youth ages 3-16)
 Child
Sexual Behavior Inventory (CSBI)
(completed by caregiver of youth ages 2-12)
 Parent
Stress Inventory
(completed by caregiver for youth ages 1mo. to 12 years)
35
Challenge: Maintaining Consistent Use
of Consultation

Coordinating consultation calls

Prioritizing attendance at consult calls

Providing audio taped sessions for review

Ensuring supervisory follow-up on consultant’s
recommendations
36
Challenge: Understanding the Fit
Between Wraparound and TF-CBT
Wraparound
Model Type
Process
Outcomes
Service Delivery
Team-Based Planning
Individualized Services
Youth & Family
Functioning
Family-Focus
Parent Voice & Choice
Empowerment
Natural supports
TF-CBT
Treatment
Therapist-Guided
Trauma-Related
Symptoms
Parent/Child/ParentChild Sessions
Psychoeducation
Trauma Processing
37
Recommendations

Prepare TF-CBT training seminar participants with
understanding of on-going commitment to
consultation.

Provide a script for Wrap Facilitators for
introducing the therapy to CFT members as a
service option.

Recognize the key elements in common between
Wrap and the EBP offered.
38
References

Cohen, J.A., Deblinger, E., & Mannarino, A. (2004). Trauma-focused
cognitive behavioral therapy for sexually abused children.
Psychiatric Times, 21 (10), pp.

Eber, L., Sugai, G., Smith, AC.R., & Scott, T.M. (2002). Wraparound
and Positive Behavioral Interventions and Supports in the Schools.
Journal of Emotional and Behavioral Disorders, Vol 10 (3), pp 171180.

Scott, T.M. & Eber, L. (2003). Functional Assessment and Wraparound as
Systemic School Processes: Primary, Secondary, and Tertiary Systems
Examples. Journal of Positive Behavior Interventions, 5 (3), pp 131-143.

VanDenBerg, J. & Grealish, E.M. (1996). Individualized services and
supports through the wraparound process: Philosophy and procedures.
Journal of Child and Family Studies, (1) , pp
39
Contact Information
Eleanor Castillo, Ph.D., Corporate Director,
Outcomes & Quality Assurance
Email: eleanor.castillo@sbcglobal.net
Lisa Davis, LMFT, Clinical Director
Email: ldavis@emq.org
Kathy Cox, LCSW, Ph.D., Clinical Director
Email: kcox@emq.org
40