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21st Annual RTC Conference Presented in Tampa, February 2008 1 I. I. “No Wrong Door No Wrong Door” Implementation of Wraparound in Implementation of Wraparound in Montgomery County, Maryland Montgomery County, Maryland Kiran Dixit, LCPC and Ayesha Bajwa, MS Ed. Kiran Dixit, LCPC and Ayesha Bajwa, MS Ed. II. Findings from the Wraparound Fidelity Index (WFI) & the Child & II. Findings from the Wraparound Fidelity Index (WFI) & the Child & Adolescent Needs and Strengths Assessment (CANS) Adolescent Needs and Strengths Assessment (CANS) Bruno Anthony, PhD and Jennifer Mettrick, MHS Bruno Anthony, PhD and Jennifer Mettrick, MHS Vicki Effland, PhD Vicki Effland, PhD Systems of Care Research and Training Center Systems of Care Research and Training Center 21st Annual Research Conference 21st Annual Research Conference February 25, 2008 February 25, 2008 I. I. “No Wrong Door No Wrong Door” Implementation of Wraparound in Implementation of Wraparound in Montgomery County, Maryland Montgomery County, Maryland Kiran Dixit, LCPC Kiran Dixit, LCPC Montgomery County Collaboration Council for Children, Youth Montgomery County Collaboration Council for Children, Youth & Families & Families Ayesha Bajwa, MS Ed. Ayesha Bajwa, MS Ed. Maryland Choices, LLC Maryland Choices, LLC Systems of Care Research and Training Center Systems of Care Research and Training Center 21st Annual Research Conference 21st Annual Research Conference February 25, 2008 February 25, 2008 Montgomery County Montgomery County (location and demographics) (location and demographics) Montgomery County, located just north of Washington, DC and southwest of Baltimore, Maryland is considered to be a part of both the Baltimore and Washington DC Metropolitan areas. With an estimated population of 956,000 in FY 2007, Montgomery County continues to be the most populous jurisdiction in Maryland. Montgomery County is a widely diverse jurisdiction with a growing international immigrant population. International migration is second only to births as a component of Montgomery County’s population growth. Over 80,000 people born outside the United States moved to Montgomery County between 2000 and 2006. Forty percent of Maryland’s foreign born population lives in Montgomery County. Collaboration Council Collaboration Council The Collaboration Council (510 c 3) is a state mandated The Collaboration Council (510 c 3) is a state mandated Local Management Board (LMB) for Montgomery County Local Management Board (LMB) for Montgomery County supported by the Governor supported by the Governor’ s Office for Children. s Office for Children. Our mission is to improve the well-being of children, Our mission is to improve the well-being of children, youth and families in Montgomery County through youth and families in Montgomery County through collaborative partnerships. collaborative partnerships. The Collaboration Council plans, coordinates, funds and The Collaboration Council plans, coordinates, funds and monitors specific interagency services to improve child monitors specific interagency services to improve child well being in Montgomery County. well being in Montgomery County. No Wrong Door No Wrong Door “ Montgomery County began developing a System of Care for children and adolescents in the early 1990s using state funds to return or divert RTC level youth from a higher level of care, this funding was focused on assisting youth at the top 5% of the needs triangle. 1999 Montgomery County received a SAMSHA funding for SOC that laid the foundation for a strong system of care including wraparound and an independent family support organization. 2005 Collaboration Council and Montgomery County Department of Health and Human Services released an RFP for wraparound, Choices Inc. was awarded the contract to begin Maryland Choices. Served two populations of youth Return/Divert from Residential Treatment Center placements Seriously Developmentally Disabled youth (Autism Spectrum) 2006 Maryland Choices became the Care Management Entity for both Montgomery County and Baltimore City through a joint RFP process. Joined Fiscal and Clinical responsibility in accordance with system of care principles and wraparound values Development of a Provider Network 2006 Montgomery County Department of Health and Human Services secured funding to allow youth in the top 15% of the needs triangle to receive services through wraparound. Thereby creating – “No Wrong Door” for families to access services and care. Expanded referral sources by allowing school personnel, community providers and parents refer youth for Expanded eligibility offered wraparound to youth who were truant, having behavioral problems, gang involved, undocumented, and/or have one or more psychiatric hospitalizations Developing a CME Developing a CME

Montgomery County Collaboration Councilrtckids.fmhi.usf.edu/rtcconference/handouts/pdf/21/Session 35/dixit.pdfMontgomery County, Maryland Kiran Dixit, LCPC Montgomery County Collaboration

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21st Annual RTC ConferencePresented in Tampa, February 2008

1

I. I. ““No Wrong DoorNo Wrong Door”” Implementation of Wraparound in Implementation of Wraparound inMontgomery County, MarylandMontgomery County, Maryland

Kiran Dixit, LCPC and Ayesha Bajwa, MS Ed.Kiran Dixit, LCPC and Ayesha Bajwa, MS Ed.

II. Findings from the Wraparound Fidelity Index (WFI) & the Child &II. Findings from the Wraparound Fidelity Index (WFI) & the Child &Adolescent Needs and Strengths Assessment (CANS)Adolescent Needs and Strengths Assessment (CANS)

Bruno Anthony, PhD and Jennifer Mettrick, MHS Bruno Anthony, PhD and Jennifer Mettrick, MHSVicki Effland, PhDVicki Effland, PhD

Systems of Care Research and Training CenterSystems of Care Research and Training Center21st Annual Research Conference21st Annual Research Conference

February 25, 2008February 25, 2008

I. I. ““No Wrong DoorNo Wrong Door”” Implementation of Wraparound in Implementation of Wraparound inMontgomery County, MarylandMontgomery County, Maryland

Kiran Dixit, LCPCKiran Dixit, LCPCMontgomery County Collaboration Council for Children, YouthMontgomery County Collaboration Council for Children, Youth

& Families& Families

Ayesha Bajwa, MS Ed.Ayesha Bajwa, MS Ed.Maryland Choices, LLCMaryland Choices, LLC

Systems of Care Research and Training CenterSystems of Care Research and Training Center21st Annual Research Conference21st Annual Research Conference

February 25, 2008February 25, 2008

Montgomery CountyMontgomery County(location and demographics)(location and demographics)

Montgomery County, located just north of Washington, DC andsouthwest of Baltimore, Maryland is considered to be a part of boththe Baltimore and Washington DC Metropolitan areas.

With an estimated population of 956,000 in FY 2007, MontgomeryCounty continues to be the most populous jurisdiction in Maryland.

Montgomery County is a widely diverse jurisdiction with a growinginternational immigrant population.

International migration is second only to births as a component of MontgomeryCounty’s population growth.

Over 80,000 people born outside the United States moved to MontgomeryCounty between 2000 and 2006.

Forty percent of Maryland’s foreign born population lives in Montgomery County.

Collaboration CouncilCollaboration Council The Collaboration Council (510 c 3) is a state mandatedThe Collaboration Council (510 c 3) is a state mandated

Local Management Board (LMB) for Montgomery CountyLocal Management Board (LMB) for Montgomery Countysupported by the Governorsupported by the Governor’’s Office for Children.s Office for Children.

Our mission is to improve the well-being of children,Our mission is to improve the well-being of children,youth and families in Montgomery County throughyouth and families in Montgomery County throughcollaborative partnerships.collaborative partnerships.

The Collaboration Council plans, coordinates, funds andThe Collaboration Council plans, coordinates, funds andmonitors specific interagency services to improve childmonitors specific interagency services to improve childwell being in Montgomery County.well being in Montgomery County.

““No Wrong Door No Wrong Door ““ Montgomery County began developing a System of Care for children and

adolescents in the early 1990s using state funds to return or divert RTC levelyouth from a higher level of care, this funding was focused on assisting youthat the top 5% of the needs triangle.

1999 Montgomery County received a SAMSHA funding for SOC that laid thefoundation for a strong system of care including wraparound and anindependent family support organization.

2005 Collaboration Council and Montgomery County Department of Healthand Human Services released an RFP for wraparound, Choices Inc. wasawarded the contract to begin Maryland Choices.

Served two populations of youth• Return/Divert from Residential Treatment Center placements• Seriously Developmentally Disabled youth (Autism Spectrum)

2006 Maryland Choices became the Care Management Entity for bothMontgomery County and Baltimore City through a joint RFP process.

Joined Fiscal and Clinical responsibility in accordance with systemof care principles and wraparound valuesDevelopment of a Provider Network

2006 Montgomery County Department of Health and Human Servicessecured funding to allow youth in the top 15% of the needs triangle toreceive services through wraparound. Thereby creating – “No WrongDoor” for families to access services and care.

Expanded referral sources by allowing school personnel,community providers and parents refer youth forExpanded eligibility offered wraparound to youth who were truant,having behavioral problems, gang involved, undocumented, and/orhave one or more psychiatric hospitalizations

Developing a CMEDeveloping a CME

21st Annual RTC ConferencePresented in Tampa, February 2008

2

Strategies for Outreach and Education aboutStrategies for Outreach and Education aboutSOC and WraparoundSOC and Wraparound

Consistent Outreach - Although the community had been introduced to SOCprinciples and Wraparound Values through the SAMSHA grant, extensive work wasdone in partnership between the Collaboration Council and Maryland Choices toreach system partners and re-introduce/re-educate our referral sources about whatwas available for children and youth. Outreach efforts were made to:

Child Welfare/DSS Department of Juvenile Services (DJS) Juvenile Court Judges State’s Attorney Public Defenders School Social Workers Pupil Personnel Workers (School) Local Coordinating Council Members Residential Treatment Centers Mental Health Providers Community Centers

“Lunch and Learn” This is a forum where system partners are invited to learn aboutand discuss their experiences on child and family team. Since our agency andcommunity partners are essential to successful teams, we work hard to ensure theyknow what to expect as they participate in a high fidelity wraparound process and thatthey begin to understand that this is a needs driven not service driven process.

Demographics of Youth ServedDemographics of Youth Served

Average Age at Intake: 13.7

Gender: Female: 30.9% Male: 69.1

Race: 39.1% African American 21.2% Caucasian 5.9% Biracial 1.0% Asian/Pacific Islander 0.3%Native American 22.3% Other 10.2% Unknown

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Gender

Male

Female

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Race

African

American

Caucasian

Biracial

Asian/Pacific

Islander

Native

American

Other

Unknown

Referring Agency:•27.9% Mont. Co. Public Schools•25.6% Dept. of Juvenile Services/ DJS•10.3% Child Welfare/DSS•16.6% Community Agency•11.8% Community Professional•4.9% Core Service Agency• 2% Family• 1% Local Coordinating Council

Diagnoses (Top 4):44.5% Mood Disorder19.8% ADHD12.4% Conduct/Oppositional/Anxiety 8.1% Co-Occurring Disorder (2 or more Axis 1 Diagnosis 58.80%)

Demographics of Youth ServedDemographics of Youth Served

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Referral

Source

School

DJS

Child Wefare

Community

Agency

Community

Professional

Core Service

Family

LCC

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

Top 4 Diagnosis

Mood D/O

ADHD

Conduct/Oppositional /Anxiety

Co-Occuring

Growth of Wraparound inGrowth of Wraparound inMontgomery CountyMontgomery County

Started FY 2006 4 youth returning from RTC 24 youth with Developmental Disabilities 2 service providers for RTC level youth

• 1 Mentoring Provider• 1 Tutoring Provider

Ended FY 2007 350 youth served in 2 years 72 providers in an organized provider network

• Diverse network designed to meet the needs of youth andfamilies as identified by the Child and Family Teams

Outcomes for FY 2007Outcomes for FY 2007

350 youth served of which 257 were newkids enrolled in FY07

88% of youth remained at or reducedlevel of restrictiveness of placement

86% of youth attended school at least80% of the days school was available

72 Providers are contracted with MarylandChoices to provide services for familiesand children with mental health needs

CANS & WFICANS & WFI Maryland Choices has imbedded the CANS into

their treatment planning process with families.All families receive CANS assessments at intakewith follow-up assessments at 90 day intervals.

University of Maryland’s Innovations Institutemonitors Maryland Choices for fidelity using theWFI

These two instruments together may provideMaryland Choices with greater information onways to improve youth outcomes throughimproved fidelity.

21st Annual RTC ConferencePresented in Tampa, February 2008

3

II: Findings from the Wraparound Fidelity IndexII: Findings from the Wraparound Fidelity Index(WFI) and the(WFI) and the

Child & Adolescent Needs and StrengthsChild & Adolescent Needs and StrengthsAssessment (CANS)Assessment (CANS)

Bruno Anthony, PhD & Jennifer Mettrick, MHSBruno Anthony, PhD & Jennifer Mettrick, MHSChild and Adolescent Innovations InstituteChild and Adolescent Innovations Institute

Department of Psychiatry, University of Maryland, BaltimoreDepartment of Psychiatry, University of Maryland, Baltimore

Vicki Effland, PhD Choices, Inc.Vicki Effland, PhD Choices, Inc.

Systems of Care Research and Training CenterSystems of Care Research and Training Center21st Annual Research Conference21st Annual Research Conference

February 25, 2008February 25, 2008

Purpose of WFIPurpose of WFI

The Wraparound Fidelity Index (WFI) is a set ofThe Wraparound Fidelity Index (WFI) is a set ofinterviews conducted with key informants whointerviews conducted with key informants whoare involved in wraparound implementationare involved in wraparound implementation

Taken together, these interviews measure theTaken together, these interviews measure thequality or quality or ““fidelityfidelity”” of wraparound implementation of wraparound implementationin a community, program, or site.in a community, program, or site.

The WFI-4 measures how well both theThe WFI-4 measures how well both theprinciplesprinciples and core and core activitiesactivities are implemented are implemented

It is organized by the 4 phases of wraparoundIt is organized by the 4 phases of wraparound

WFI Total & Element ScoresWFI Total & Element ScoresData Collected Sept 2006 Data Collected Sept 2006 –– December 2007 (N=102 Youth Teams) December 2007 (N=102 Youth Teams)

0

20

40

60

80

100

Total WFI

Scores

Family Voice &

Choice

Team Based Natural

Supports

Collaborative Community

Based

Wraparound

Facilitator(N=79)

Care Giver(N=41)

Youth (N=21)

Team Member

(N=53)

WFI Total & Element ScoresWFI Total & Element Scores

0

20

40

60

80

100

Culturally Competent Individualized Strengths Based Persistent Outcomes Based

WraparoundFacilitator

(N=79)

Care Giver(N=41)

Youth (N=21)

Team

Member(N=53)

Changes In WFI Total & ElementChanges In WFI Total & ElementScores OvertimeScores Overtime

0

20

40

60

80

100

Total WFI

Scores

Family Voice &

Choice

Team Based Natural

Supports

Collaborative Community

Based

2007 Apr

2007 Jul

2008 Jan

* p<.05

*

Changes In WFI Total & ElementChanges In WFI Total & ElementScores Over TimeScores Over Time

0

20

40

60

80

100

Culturally

Competent

Individualized Strengths

Based

Persistent Outcomes

Based

2007 Apr

2007 Jul

2008 Jan

*

*

* p<.05

21st Annual RTC ConferencePresented in Tampa, February 2008

4

Correlations Between WFI TotalCorrelations Between WFI TotalFidelity Scores for DifferentFidelity Scores for Different

RespondentsRespondents

-0.4 -0.2 0 0.2 0.4 0.6 0.8

Pearson r

Coordinator-Caregiver

Coordinator-Team Member

Coordinator-Youth

Caregiver-Team Member

Caregiver-Youth

Team Member-Youth 15

15

24

19

41

32

*

* p<.01

Child and Adolescent Needs and StrengthsChild and Adolescent Needs and StrengthsAssessment (CANS) DimensionsAssessment (CANS) Dimensions

Provides a structured assessment of childrenProvides a structured assessment of childrenand families along a set of dimensions relevantand families along a set of dimensions relevantto service planning and decision making.to service planning and decision making. Child StrengthsChild Strengths Life Domain FunctioningLife Domain Functioning AcculturationAcculturation Child Behavioral/Emotional NeedsChild Behavioral/Emotional Needs Child Risk BehaviorsChild Risk Behaviors Caregiver Needs and StrengthsCaregiver Needs and Strengths

CANS Changes: Intake to DischargeCANS Changes: Intake to Discharge

0 0.5 1 1.5 2

Child Strengths

Life Domain

Acculturation

Child Needs

Child Risks

Caregiver Needs

Dimension Score

Discharge Intake

*

*

*

*

*

* p< .05

-0.4

-0.3

-0.2

-0.1

0

0.1

0.2

0.3

0.4

Pe

ars

on

r

Coordinator Caregiver Team Member

Strengths Life Domains Acculturation

Child Needs Child Risk Caregiver Needs

Relations Between Total WFI Score and DischargeRelations Between Total WFI Score and DischargeCANS Scores for the Different DomainsCANS Scores for the Different Domains

**

* *

SummarySummary Overall Overall ““goodgood”” fidelity to Wraparound was obtained fidelity to Wraparound was obtained

Facilitator ratings tended to be higher than other respondentsFacilitator ratings tended to be higher than other respondents Higher fidelity ratings for key elements of Wraparound: FamilyHigher fidelity ratings for key elements of Wraparound: Family

Voice and Choice, Collaborative, Cultural Competence, StrengthVoice and Choice, Collaborative, Cultural Competence, StrengthBasedBased

Lower ratings for Natural SupportsLower ratings for Natural Supports Different levels of agreement among respondentsDifferent levels of agreement among respondents

Improvement in most dimensions of child needs andImprovement in most dimensions of child needs andstrengths over course of wraparound treatmentstrengths over course of wraparound treatment

Relation between levels of child and family functioningRelation between levels of child and family functioningand fidelity may be complex and may vary byand fidelity may be complex and may vary byrespondentrespondent..

ResourcesResources CANSCANS

www.BuddinPraed.orgwww.BuddinPraed.org Lyons, J.S. (2004). Lyons, J.S. (2004). Redressing the Emperor: Improving OurRedressing the Emperor: Improving Our

ChildrenChildren’’s Public Mental Health Systems Public Mental Health System. Westport, CT: . Westport, CT: PraegerPraeger WFIWFI

http://http://depts.washington.edu/wrapevaldepts.washington.edu/wrapeval BrunsBruns, E.J., , E.J., SuterSuter, J.S., Force, M.D., & , J.S., Force, M.D., & BurchardBurchard, J.D. (2005)., J.D. (2005).

Fidelity to the wraparound process and its association withFidelity to the wraparound process and its association withoutcomes. outcomes. Journal of Child and Family Studies, 14, 521-534.Journal of Child and Family Studies, 14, 521-534.

BrunsBruns, E.J., , E.J., BurchardBurchard, J.D., , J.D., SuterSuter, J.C., & Force, M.D. (2005)., J.C., & Force, M.D. (2005).Measuring fidelity within community treatments for children andMeasuring fidelity within community treatments for children andfamilies. In Epstein, M., families. In Epstein, M., DuchnowskiDuchnowski, A., & , A., & KutashKutash, K. (Eds.), K. (Eds.)Outcomes for Children and Youth with Emotional and BehavioralOutcomes for Children and Youth with Emotional and BehavioralDisorders and their Families, vol. 2. Disorders and their Families, vol. 2. Austin, TX: Pro-ED.Austin, TX: Pro-ED.