Transcript The Evidence Base for Wraparound and StrengthsBased Approaches Eric J. Bruns, Ph.D. University of Washington School of Medicine ([email protected]) National Wraparound Initiative (www.wrapinfo.org) Washington State.

The Evidence Base for
Wraparound and StrengthsBased Approaches
Eric J. Bruns, Ph.D.
University of Washington School of Medicine ([email protected])
National Wraparound Initiative (www.wrapinfo.org)
Washington State Children’s MH Evidence Based Practices Institute
(http://depts.washington.edu/pbhjp)
Presented at the CASSP 25th Anniversary Systems of Care Program
Annual Meeting of the American Academy of Child and Adolescent Psychiatry
October 26, 2009
Honolulu, Hawaii
1
Acknowledgments

The work described in this presentation has been
funded by a variety of sources, including:





The Child, Adolescent, and Family Branch of the Center
for Mental Health Services, SAMHSA
The National Institute of Mental Health (R34 MH072759;
R41 MH077356)
The American Institutes for Research and National
Technical Assistance Partnership
The Maryland Child Mental Health and Innovations
Institute
The presenter received support to travel to Honolulu
to today’s meeting and is receiving an honorarium. He
has no conflict of interest to disclose.
2
John D. Burchard, University of Vermont
(1936-2004)
3
Wraparound Process
Principles
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Family voice and choice
Team-based
Natural supports
Collaboration
Community-based
Culturally competent
Individualized
Strengths based
Unconditional commitment and persistence
Outcome-based
Walker, Bruns, Adams, Miles, Osher et al.,
2004 (see www.wrapinfo.org)
4
The Strengths Perspective…

“The Strengths Perspective obligates workers to
understand that, however downtrodden… individuals
have survived (and thrived). They have taken steps,
summoned up resources, and coped. We need to
know what they have done, how they have done it,
what they have learned from doing it, and what
resources (inner and outer) were available in their
struggle to surmount their challenges. As helpers, we
must tap into that work, elucidate it, find and build
on its possibilities.”

Saleeby (1992), pp. 171-172
5
Practices involved in strengths-based
service delivery

An Empowering orientation

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Cultural competence


That works to develop a supportive relationship between program
staff and family members, and that…
Strengthens families


Including understanding and valuing a family’s culture as a source of
strength
A relationship-based approach

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Services are provided in ways that build on family members’
strengths and empower them to do things for themselves
By improving relationships within and across families
Active partnering

Between family members and program staff
6
Practices involved in strengths-based
service delivery (cont’d)

Community orientation
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A family-centered approach
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That includes the entire family rather than focusing on a specific
individual
Goal-orientation
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Including sensitivity to community history and
Knowledge of community-based providers
That helps families not only with immediate crises but also with
identifying and realizing long-term goals
Individualization of services

To address specific family needs

Based on a review by Green, McAllister, & Tarte (2004) that includes Dunst
et al., 1994; Herman, Marcenko, & Hazel, 1996; Kagan & Shelley, 1987;
Koren, DeChillo, & Friesen, 1992
7
Strengths-Based Services & Supports
(Adapted from Green et al., 2004)
PHILOSOPHY
Strengths
Based
Services &
Supports
ENGAGEMENT
Engagement
in Strategies
and Services
Relationships
with Helpers
OUTCOMES
Family and
youth efficacy
and
empowerment
Better Followthrough with
services/
strategies
Relationships
and social
support
Other family
outcomes
Child/youth
outcomes
8
Is there Evidence for Strengths-Based
Services?
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Staudt, Howard, & Drake, 2001
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Few evaluations of SBS
Existing studies not rigorous enough to determine
whether outcomes are due to strengths
perspective or delivery of additional services
Directives of the strengths perspective not
adequately operationalized or measured
Concluded that “the strengths perspective is more
a value stance than a unique practice model”
(p.19)
9
Making Progress: Operationalization

E.g., The ADMIRE framework (Franz, 2008)
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Attitude
Discovery
Mirroring
Intervention
Recording
Evaluation
See also:
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Nissen, 2006 (Juvenile Justice)
Rawanda & Brownlee, 2009 (Social Work)
10
Making Progress: Measurement

Assessment based on strengths

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Degree of strengths orientation in practice

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Behavioral and Emotional Rating Scale (Epstein &
Sharma, 1998); Child and Adolescent Needs and
Strengths (CANS; Lyons et al.)
Strengths-Based Practices Inventory (SBPI; Green,
McAllister, & Tarte, 2004)
Assessment tools to assist planning and provision of
services

E.g., Personal Strengths Grid (Cox, 2008)
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Making Progress: Empirical Support

Cox, 2006, Randomized control study of child MH
therapists
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Strengths-based assessment (SBA)  higher parent
satisfaction and fewer missed appointments than
assessment as usual
Use of SBA + therapist strengths orientation  improved
child functioning outcomes
Green et al., 2004, cross-sectional study of family
support programs:

Greater strengths orientation as assessed by the SBPI 
family empowerment and social support

but not better child behavior or improved parent skills
12
Wraparound Process
Principles
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Family voice and choice
Team-based
Natural supports
Collaboration
Community-based
Culturally competent
Individualized
Strengths based
Unconditional commitment and persistence
Outcome-based
Walker, Bruns, Adams, Miles, Osher et al.,
2004 (see www.wrapinfo.org)
13
Wraparound



Principles: A philosophy or approach to service
delivery (broadly defined and applicable to any
practice)
Practice: A defined, team-based, individualized
practice model for planning and implementing
services and supports for youth and families with the
most complex needs
System: Characteristics of a system or program that
are necessary to support implementation per the
wraparound principles and practice model
14
What is Wraparound?

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Wraparound is a family-driven, youth guided, team-based
process for planning and implementing services and supports.
Through the wraparound process, teams create plans that are
geared toward meeting the unique and holistic needs of
children and youth with complex needs and their families.
The wraparound team members (e.g., the identified youth, his
or her parents/caregivers, other family members and
community members, mental health professionals, educators,
and others) meet regularly to implement and monitor the plan
to ensure its success.
15
For which children and youth is the
wraparound process intended?

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Youth with needs that span home, school, and
community
Youth with needs in multiple life domains

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(e.g., school, employment, residential stability,
safety, family relationships, basic needs)
Youth for whom there are many adults
involved and they need to work together well
for him or her to succeed
16
For which youth in a system of care?
More
complex
needs
Most Intensive
intervention
level
Targeted
Intervention
Level
Prevention and
Universal Health
Promotion
Level
Less complex
needs
2% Full Wraparound
Process
3%
15%
Targeted and
Individualized
Services
80%
17
Who is served by wraparound?
An example from Washington State

Of the 116,209 served by
CA, JRA, and/or MHD in
2003 (smaller circles),
about 9 percent (4,030) of
these children and youth
received MH services from
two or more
administrations:
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3,547 From CA and MHD
368 From JRA and MHD
35 From CA and JRA
80 From CA, MHD, and
JRA
18
Why should we find a different way to
work with these youth and their families?

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In Fiscal Year 2002, over 126,000
children and youth received
services from three DSHS
programs: CA, JRA, and|or MHD.
44,900 of these children and youth
received at least one mental health
service from one of the systems
during that year.
Collectively, the mental health
services for those 44,900 young
people cost $169 million.
Half of that expenditure ($81
million) was spent on the 9
percent who received mental
health care from two or more
programs.
19
Why should we find a different way to
work with these youth and their families?

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In 2003, of the 39,361 children
and youth who used mental health
services one program (CA, JRA,
or MHD), 14 percent spent some
time in treatment or placement
away from home.
In 2003, of the 4,030 children
who used mental health care from
two or three administrations, 68
percent spent some time in
treatment or placement away from
home.
Typically, those spending time
away from home are in foster
care, inpatient or residential
treatment, or a JRA institution. 20
Until proven otherwise, we believe that all
parents want to…
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Be proud of their child
Have a positive influence on their child
Hear good news about their child and about what
their child does well
Provide their child a good education and a good
chance of success in life
See their child’s future as better than their own
Have a good relationship with their child
Feel hopeful about their child
Believe they are good parents
21
Laura Burger Lucas, ohana coaching, 2009; adapted from the work of Insoo Kim Berg
Until proven otherwise, we believe all
children want to…
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Have their parents be proud of them
Please their parents and other adults
Be accepted as a part of a social group
Be active and involved in activities with others
Learn new things
Be surprised and surprise others
Voice their opinions and choices
Make choices when given an opportunity
22
Laura Burger Lucas, ohana coaching, 2009; adapted from the work of Insoo Kim Berg
A practice model:
The Four Phases of Wraparound
Phase
1A
Engagement and Support
Phase
1B
Team Preparation
Phase
2
Initial Plan Development
Phase
3
Implementation
Phase
4
Transition
Time
23
Phase 1 A and B
Phase 1 : Engagement and Team Preparation

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Care Coordinator & Family Support Partner meets with the
family to discuss the wraparound process and listen to the family’s
story.
Discuss concerns, needs, hopes, dreams, and strengths.
Listen to the family’s vision for the future.
Assess for safety and make a support plan if needed
Identify people who care about the family as well as people the
family have found helpful for each family member.
Reach agreement about who will come to a meeting to develop a
plan and where we should have that meeting.
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Phase 2
Phase 2: Initial Plan Development
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Conduct first Child & Family Team (CFT) meeting with people
who are providing services to the family as well as people who are
connected to the family in a supportive role.
The team will:
 Review the family vision
 Develop a Mission Statement about what the team will be
working on together
 Review the family’s needs
 Come up with several different ways to meet those needs that
match up with the family’s strengths
Different team members will take on different tasks that have been
agreed to.
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Phase 3
Phase 3: Plan Implementation and
Refinement
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Based on the CFT meetings, the team has created a written
plan of care.
Action steps have been created, team members are committed
to do the work, and our team comes together regularly.
When the team meets, it:
 Reviews Accomplishments (what has been done and
what’s been going well);
 Assesses whether the plan has been working to achieve
the family’s goals;
 Adjusts things that aren’t working within the plan;
 Assigns new tasks to team members.
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Phase 4
Phase 4: Transition
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There is a point when the team will no longer need to meet
regularly.
Transition out of Wraparound may involve a final meeting of
the whole team, a small celebration, or simply the family
deciding they are ready to move on.
The family we will get a record of what work was completed
as well as list of what was accomplished.
The team will also make a plan for the future, including who
the family can call on if they need help or if they need to reconvene their team.
Sometimes transition steps include the family and their
supports practicing responses to crises or problems that may
arise
27
Ten principles of the
wraparound process
Model adherent
wraparound
•Youth/Family drives
goal setting
Theory of change for wraparound process
Short term
outcomes:
•Better
engagement in
service delivery
Intermediate
outcomes:
•Participation in
services
•Services that
“work” for family
•Stable, homelike
placements
•Improved
mental health
outcomes
(youth and
caregiver)
•Single, collaboratively
designed service plan
•Creative plans
that fit the needs
of youth/family
•Active integration of
natural supports and
peer support
•Improved service
coordination
Intermediate
outcomes:
•Follow-through
on team decisions
•Achievement of
team goals
•Family regularly
experiences
success/support
•Increased social
support and
community
integration
•Respect for family’s
culture/expertise
•Opportunities for
choice
•Active evaluation of
strategies/outcomes
•Improved coping
and problem solving
•Celebration of success
•Enhanced
empowerment
Phases and Activities
of the Wraparound
Process
From Walker (2008)
Long term
outcomes:
•Enhanced
optimism/selfesteem
•Improved
functioning in
school/
vocation and
community
•Improved
resilience and
quality of life
28
When wraparound is implemented as
intended…
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Basing plans on strengths, needs, and culture leads to more complete
engagement of families
High-quality teamwork and flexible funds leads to better plans,
better fit between family needs and supports, and greater
integration of effort by helpers
 Greater relevance, less dropout, better follow-through
As family works with a team to solve its own problems, develops
family members’ skills and self-efficacy
Process focuses on developing supportive relationships
Focus on setting goals and measuring outcomes leads to more
frequent problem-solving, more effective plans, greater success
29
Wraparound implementation is
widespread and increasing

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87.8% of states (43 of 49) have at least one
wraparound initiative
26 states now have a statewide initiative
From estimates provided by states, 98,293
children were served by wraparound in 2008,
in a reported 819 unique programs
(Sather, Bruns, & Stambaugh, 2008)
30
Several factors are promoting expansion of
wraparound implementation
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Alignment with youth and family movements
Fills a gap in the public health continuum
Serves a central role in implementing the systems of
care framework
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Addresses concerns of youth with complex needs,
regardless of referring agency
Facilitates shared effort by many agencies that otherwise
wouldn’t work well together
Can be flexibly applied to respond to different agencies’
target populations in one state or community
The evidence base continues to expand…

Bruns, Walker, et al., in press
31
Outcomes of Wraparound
Does wraparound work?
For whom?
What is associated with positive outcomes?
32
Is there evidence for wraparound?

Recent summaries of the evidence base skeptical and
still often cited
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“The existing literature does not provide strong support
for the effectiveness of wraparound” (Bickman, Smith,
Lambert, & Andrade, 2003; p. 138).
Farmer, Dorsey, and Mustillo (2004) recently
characterized the wraparound evidence base as being “on
the weak side of ‘promising’” (p. 869).
However, since 2003:
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Five controlled (experimental or quasi-experimental
studies) have been published
First meta-analysis published (Suter & Bruns, 2009)
First NIMH-funded studies of wraparound underway
33
Results from Nevada:
Average Functional Impairment on the CAFAS
Impact on Child Functioning
Traditional Svcs
Wraparound
120
100
80
60
40
20
0
Intake
6 months
12 months
18 months
Bruns et al. (2006)
34
Results from Clark County, WA
Impact on juvenile justice outcomes
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Connections (wraparound) group (N=110) 3 times less
likely to commit felony offense than comparison group
(N=98)
Connections group took 3 times longer on average to
commit first offense after baseline
Connections youth showed “significant improvement in
behavioral and emotional problems, increases in
behavioral and emotional strengths, and improved
functioning at home at school, and in the community”
Pullman et al. (2006)
35
Results from Ohio RCT of wraparound for
youth involved with JJ
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Wraparound group
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Missed less school
Suspended less often
Less likely to run from home
Less assaultive
Less likely to be stopped by police
However…
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Between-group differences in arrests and incarceration
were not significant.

(Carney & Buttell, 2003)
36
Meta analysis of Seven Published Controlled
Studies of Wraparound
Study
Target
population
Control Group Design
N
1. Bickman et al. (2003)
Mental health
Non-equivalent comparison
111
2. Carney et al. (2003)
Juvenile justice
Randomized control
141
3. Clark et al. (1998)
Child welfare
Randomized control
132
4. Evans et al. (1998)
Mental health
Randomized control
42
5. Hyde et al. (1996)
Mental health
Non-equivalent comparison
69
6. Pullman et al. (2006)
Juvenile justice
Historical comparison
204
7. Rast et al. (2007)
Child welfare
Matched comparison
67
37
Mean Effect Sizes & 95%
Confidence Intervals
38
Findings from our meta-analysis of
seven controlled studies
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Strong results in favor of wraparound found for
Living Situation outcomes (placement stability and
restrictiveness)
A small to medium sized effect found for:
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Mental health (behaviors and functioning)
School (attendance/GPA), and
Community (e.g., JJ, re-offending) outcomes
The overall effect size of all outcomes in the 7
studies is about the same (.35) as for “evidencebased” treatments, when compared to services as
usual (Weisz et al., 2005)
Suter & Bruns (2008)
39
Other unpublished outcomes of
wraparound
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Greater/more rapid achievement of permanency
when implemented in child welfare (Oklahoma)
Reduced recidivism among adult prisoners
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95% survival at 27 mos post-release for “PrisonWrap”
condition vs. 70% for TAU
Reduction in costs associated with residential
placements (Milwaukee, LA County, Washington
State, Kansas, many other jurisdictions)
40
Outcomes from Wraparound
Milwaukee

After Wraparound Milwaukee assumed
responsibility for youth at residential level of
care (now approx 1300 per year)…

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Average daily Residential Treatment population reduced
from 375 placements to 70 placements
Psychiatric Inpatient Utilization reduced from 5000 days
per year to under 200 days (average LOS of 2.1 days)
Reduction in Juvenile Correctional Commitments from
325 per year to 150 (over last 3 years)
(Kamradt et al., 2008)
41
LA County DSS Wraparound
Outcomes for N=102 wraparound graduates vs. matched group of
N=210 youth discharged from Group Care (RCL12-14)
Percentage of Children whose
Cases Closed within 12 Months
100
Percentage of Children Who Had
None versus at Least One Out-ofHome Placement
91.0
80
58%
50
16%
Percentage of Children
Percentage of Children
100
55.8
60
44.2
40
20
9.0
0
0
Wraparound (N=102) RCL 12-14 (N=210)
No Placement
Wraparound (N=43)
Rauso et al (2009)
One or More Placements
RCL 12-14 (N=177)
42
LA County DSS Wraparound
Outcomes for N=102 wraparound graduates vs. matched group of
N=210 youth discharged from group care (RCL12-14)
Average Out-of-Home
Placements Costs
Average Number of Days in
Out-of-Home Placements
Average Cost per Child
Average Number of Days
300
200
$30,000
290
193
100
0
$27,383*
$20,000
$10,737*
$10,000
$0
Wraparound (N=43)
Rauso et al (2009)
RCL 12-14 (N=177)
Wraparound
RCL 12-14
43
Outcomes are variable and related to
implementation factors
Studies indicate that Wraparound teams often fail to:
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Incorporate full complement of key individuals on the
Wraparound team;
Engage youth in community activities, things they do well, or
activities to help develop friendships;
Use family/community strengths to plan/implement services;
Engage natural supports, such as extended family members
and community members;
Use flexible funds to help implement strategies
Consistently assess outcomes and satisfaction.
44
What is the connection between
wraparound fidelity and outcomes?

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Provider staff whose families experience
better outcomes were found to score higher
on fidelity tools (Bruns, Rast et al., 2006)
Wraparound initiatives with positive
fidelity assessments demonstrate more
positive outcomes (Bruns, LeverentzBrady, & Suter, 2008)
45
Average Functional Impairment on the CAFAS
Fidelity’s Impact on Outcomes at a
state level?
140
120
WFI=69
WFI=68
100
WFI=80
WFI=81
80
60
40
20
0
Intake
6 months
12 months
State 1 (WFI=68)
118
104
105
State 2 (WFI=69)
106
102
98
State 3 (WFI=80)
113
95
79
State 4 (WFI=81)
101
81
75
46
What does it take to get high fidelity
scores?


Training and coaching found to be associated
with gains in fidelity and higher fidelity
(Bruns, Rast, et al., 2006)
Communities with better developed supports
for wraparound show higher fidelity scores
(Bruns, Suter, & Leverentz-Brady, 2006)
47
Program and system supports for Wraparound
(from the Community Supports for Wraparound Inventory)
1.
2.
3.
4.
5.
6.
Community partnership: Do we have collaboration across
our key systems and stakeholders?
Collaborative action: Do the stakeholders take concrete
steps to translate the wraparound philosophy into concrete
policies, practices and achievements?
Fiscal policies: Do we have the funding and fiscal strategies
to meet the needs of children participating in wraparound?
Service array: Do teams have access to the services and
supports they need to meet families’ needs?
Human resource development: Do we have the right jobs,
caseloads, and working conditions? Are people supported
with coaching, training, and supervision?
Accountability: Do we use tools that help us make sure
we’re doing a good job?
48
Getting to “high fidelity”
Characteristics of one “high fidelity” state

Statewide training and TA center
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Consistent availability of family partners (+ youth advocates)
Certification program for facilitators/Family Partners
Fiscal responsibility shared by multiple agencies
Referrals from multiple agencies
Care management entity (CME) that maintains MIS, develops
service array, holds some risk for overall costs

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Oversees statewide fidelity assessment using fidelity measures
Allows for flexible funding of team strategies
Encourages individualization of plans
1915c Waiver
Professional development at SSW and in provider agencies
49
Summary

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

Wraparound provides an operationalization of
strengths-based practice as well as the
CASSP/system of care principles
Its use has been widespread due to its face validity
and alignment with the family and youth movements
Evidence base has expanded to the point where
discussion as an “evidence based process” makes
sense
Fidelity controls and fidelity measurement is needed,
as is attention to necessary system-level conditions
50
The mission of the National Wraparound Initiative
is to promote understanding about the components of and benefits of
wraparound, and to provide the field with resources and guidance that facilitate
high quality and consistent wraparound implementation.
Core Functions
Community-level planning
and implementation
•Implementation blueprints
•Community self-assessment
tools
•Technical assistance
The NWI supports:
Professional development of
wraparound staff
•Core skillsets
•Implementation strategies & tools,
•Expectations for workforce
development and supervision
•Access to trainers and TA providers
Accountability
•External reviews of
practice
•Web-based tracking of
implementation, fidelity
and outcomes
NWI Infrastructure
A National Community
of Practice
Hundreds of NWI
members and affiliates
For more, see
www.wrapinfo.org
To achieve its mission, and conduct its core
functions, the NWI relies upon:
Effective communication
Website that provides access to
information, tools, and training
materials plus opportunities for
the Community of Practice to
share information and network
NWI Core Staff
University-based CoDirectors plus staff who
oversee dissemination,
communication, and
research and accountability
functions
51