Parent Management Training Oregon Model-Change Management Challenges

NetherlandsJanuary 2006 Jim Wotring

Wotringj@Michigan.gov 1-1-517-241-5775

“When pigs fly, I’ll provide an evidence based practice”

Michigan’s Initial Reaction to Evidence Based Practices

Some Staff Reaction to Change

Change Ha-Ha-Ha

Broad Participatory Planning

• Committee Identified Potential Evidence Based Practices

• Committee Reviewed Outcome Data and Made our Decision Using Data – Data Helped Create a Sense of Urgency

• Committee Selected PMTO as our Primary Evidence Based Practice

Client Types(Hierarchical, Based on CAFAS Profile, & Obvious at Intake)

Thinking Problems

Maladaptive Substance Use

Self-Harmful Potential (includes severe depression)

Delinquency

Behavior Problems with Moderate Mood Disturbance (Beh Prob =School, Home, Or Behavior Toward Others)

Behavior Problems without Mood

Moderate or Mild Mood and/or Mild Behavioral Problems

CAFAS Tiers® Hierarchical Client Types

Thinking

Maladaptive Substance Use

Self-Harmful Potential

Delinquency

Behavior Problems with Moderate Mood Disturbance

Behavior Problems without Mood

Moderate Mood

Mild Behavior or Mood

Adolescent Specialties

Client Types for Youths with SED Served by Michigan Public Health

Most Common Client Types (50.4%)

Behavior Problems

• in School,

•at Home, &

• in Social Interactions

Delinquency

14.3%

Behavior

Problems

with Mood

25.1%

Self-

Harmful

Potential

17.8%

Behavior

Problems

25.3%

Moderate/

Mild Mood

and/ or Mild

Behavior

Problems

4.1%

Maladaptive

Substance

Use

6.8%

Thinking

Problems

6.6%*

Behavior With Mood

20%

Delinquent13%

Thinking Problems

8%Substance

Use7%

Self-Harm17%

Behavior17%

Adjustment or Moderate

Mood18%

Which EBPs could help the most youth?

Cognitive Behavior

Therapy for Depression

(CBT)

Parent Management

Training (PMT)

From Evidence-based Treatments for Children And Adolescents: Matching CAFAS Profilesto Treatment Types. Hodges, 2004

Percentage of Youth Not Improving on each CAFAS Subscale: The Impetus

0%

10%

20%

30%

40%

50%

60%

% N

ot

Impro

ving

Home School BehaviorTowardOthers

Moods Community SubstanceUse

Thinking Self-Harm

CAFAS Subscales

Percent of Youths with Behavioral Impairment in the LOF Dataset for the Period of 2000-2004 (N= 16,767)

35%38% 37%

33%

66% 64% 65% 67%

93% 95% 95%91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

All youths 6-8 year olds 9-11 year olds 12-17 year olds

Age

Pe

rce

nt

of

Yo

uth

s W

ith

Imp

air

me

nt

(%)

PMTO targetcases

Severe ormoderateimpairment

Severe,moderate ormildimpairment

Initial Implementation

• Change Management Strategies (Core Planning Activities at State and Local Level)

• Theory of Change Plan-Logic Model (Collaborative Planning Process)

• Work Plan (Collaborative Planning Process

Action: Urgency •A sense of urgency had to exist or be developed (we used data, consumers, a mental health commission report, and conference etc.. Behavior to observe •People say to each other lets go we need to change things.    

Action Taken•Director described need for evidence based practices•Partners formed an large planning committee•Partners (CMH/ MDCH) held a conference to highlight need for change•Clear direction from StateBehavior Observed•People described why we need to change based on new information (or quit talking to me). •We used outcome data to help staff become more aware of their need to change and external environment (high drop out poor outcomes easy behavior disorders.

Test: Within our organization:

•Individuals asked challenging questions about why change now? Why do we need to provide evidence based practices•People developed a sense that they needed to change? •They became more aware of their external environment? Mental Health Commission helped with this.

Created a Sense of Urgency

Your Sense of Urgency May Be

• Operatie Jong (Operation Young) to Strengthen Youth Care System

• Wet op de Jeugdzorg en Bureau Jeugdzorg (CW, MH, CP)

• Behavior Disordered Children from Juvenile Detention Centers Being referred to Ministry of Health, Welfare, and Sport

• Poor Effectiveness of Current Interventions for Behavior Disorder Children

Action: •A guiding team had to be formed at a State and Community Level.•They have to be credible, have the skills, connections, reputations, and formal authority to get the job done. •They have to be a powerful enough groupBehavior to observe:•The group works well together and shows enthusiasm. 

Action Taken:•Formed committee with state, community & university representatives•Committee became emotionally committed to the change process•Informal leaders on committee inspired othersBehavior Observed:Groups work well together and problem solve

Test: •Does the team:Consistently get the resources they need to get the job done•Motivate and inspire others•Maintain a consistent approach and direction.

Built our Leadership Team

Evidence Based PracticeSteering Committee

MDCHInternal

Committee

Parent ManagementTraining SubcommitteeCharge:Implementation and Monitoring of

PMT

Training and TechnicalAssistanceWorkgroup

Chair: Heather Visingardi Chair

Administration, Policy,Finance

WorkgroupChair: Jim Wotring

Measurement (Fidelityand Outcome)

WorkgroupChair: Kay Hodges

Evidence Based Practice CommitteeStructure

Major Planning TasksConference Planning

Develop Selection CriteriaProvide Training

Provide CoachingMonitor Fidelity

Establishing Local Infrastructure

Major Planning TasksSecuring Funding

Secure Additional Medicaid $$Identify & Operationalize CPT code(s)

Establishing Organizational Supports & FeedbackLoops

Establishing Local Infrastructure

Major Planning TasksEvaluating EBP

Establish Reporting Mechanims to EvaluateFidelity & Outcomes

Information ProcessingComplete IRB Requierments

Establishing Local Infrastructure

EMU Levelof

FunctioningProject

Grant WritingMarion Forgatch

Kay HodgesDean FixsenJim Wotring

MDCH/CMHSP DDBest PracticeCommittee

Leadership

• Never forget that only dead fish swim with the stream– Malcolm Muggeridge

Team Competency-A useful tool to help the team determine if they have the right team members relative to the competencies and influence necessary to execute the initiative.

Team Member

Competency /Influence

  

         

  

         

  

         

  

         

  

         

  

         

H=High M=Medium L=Low Helps in forming team and in making adjustments to the team. Can be used at the beginning of the project and after if the project is struggling due to lack of competency or influence.

Team Competency Influence

Team Competency-A useful tool to help the team determine if they have the right team members relative to the competencies and influence necessary to execute the initiative.

Team Member

Competency /Influence

 

Understands Need for Evidence Based

Strong Agency Leader

         

         

 Strong Sponsor to support system change Political support for the system change Informal leader among peers

Strong University leader

         

  

         

  

         

  

         

H=High M= Medium L=Low Helps in forming team and in making adjustments to the team. Can be used at the beginning of the project and after if the project is struggling due to lack of competency or influence.

Team Competency Influence

Action: Vision•Are the vision and strategies clear. •Is the vision simple, clear and uplifting

Behavior to observe: The developed vision and outcomes are shared

Action Taken:•Clear simple vision and outcomes described in documents•Outcomes are clear and measurableBehavior Observed:Logic model completed

Test:•Do you know what the vision outcomes are?•Is it compelling and desirable?•Can most people who will be effected by the change articulate the vision and outcomes? 

Created a Shared Vision/Mission at a State and Community Level (Logic Model)

Parent Mangement Training Oregon - Logic ModelGoal: Improve Child and Family Well Being by Increased use of Evidence Based Practice and Outcome Management

ResourcesStaff Time

Federal Block GrantState funding

Federal GrantsFoundation Funding

System ContextPresidents new Freedom CommissionMichigan Mental Health CommissionFederal Mandates-Science to Service

Balanced Budget ActMDCH Vision and Mission statement

MACHMB Resolution Statement

Assumptions

PMTO will improve services to childrenand families

Families will like PMTO due to improvedfunctioning (less calls, less missedwork) and this will have a positiveimpact on home, school, and community

Treatment will positively affect otherfamily members

A manualized treatment will make iteasier to train new staff and retaincurrent staff

PMTO will enhance the current array ofservices∙PMTO can be used across the array ofservices (Outpatient, Home-based, andGroups)

PIHPs will work with MDCH andproblem solve as training is provided

Infrastructure will be developed at thestate and PIHP level that includesorganizational, utilization management,and performance measurement

There will be strong leadership/partnership with state and PIHPs

Data will be gathered to monitor fidelityand outcomes

Outcomes

PMTO will be implementedstatewide with model fideliy

Improved child and familyfunctioning

Improved family satisfactionwith services

Improved Parenting Skills

Improved staff skills/competency in PMTO

StrategiesBuild Awarness and Support

Build InfrastructureProvide Training

EvaluateProvide Feedback

Improve Training & Services

Measurement

FIMP

CAFAS

Family SatisfactionSession Scale

Caregiver WishlistSkill building Planner

FIMP

Action Steps Education/ Awareness Develop awareness through the MACMHB Conference Share information with stakeholders Share information with Children’s administrators at regular meetings Share information about training at conferences Share information with family members Family Involvement Ensure that families are involved throughout planning and implementation Involve families in the evaluation of data and sharing outcome information Training and Technical Assistance Purchase equipment needed for training that includes: 1) DVD video camera, 2) tripod, 3) wide angle lens, 4)\ separate michrophone, 5) computer with internet access Identify staff to be trained Identify cases to use in training(minimum of 5) Provide training to participants in use of video equipment Provide training in data collection Provide training in PMTO Complete a minimum of 3 training cases Provide ongoing feedback to trainees PIHP staff begin training others Develop a training and TA manual Put training and TA material on list serve Identify and distribute criteria for certification Develop in state capacity to train and FIMP (virtual institute) Families will receive training in PMTO Families will provide training in PMTO ACMH will provide training in family involvement/engagement/welcoming and choice in service selection

Action Steps Administrative Complete Institutional Review Board requirements Identify HCPCS Codes/Modifiers Complete RFP Selection Criteria and provide to CMHSP/PIHP Complete contracts with PIHP’s Develop new job descriptions that include PMT training Develop practice guidelines and utilization management standards for statewide use Integrate outcome management, PMTO and MDCH site review processes Include requirement to train staff in PMTO and have available in MDCH/PIHP contract Integrate families into administrative and evaluation decision making Develop plan to interface with juvenile justice and child welfare Insure PMTO is delivered in a culturally competent manner Funding Apply for R-34 Apply for R-01 Grant Make Mental Health Block Grant funds available through RFP Identify funding at CMHSP/PIHP level Develop new contracts with EMU and OSLC Measurement Support families in evaluation/measurement Expand LOF project (requiring participation) Provide education and training on the CAFAS and ensure that rater’s are reliable Develop clear process outlining what data is collected when and by whom Develop a feedback loop to inform participants about the process, fidelity, and outcomes Use data to inform decision-making process Identify improvements in the model Monitor Fidelity Develop Michigan Fidelity monitors

Action: Communication•Have you communicated the vision and strategies in simple heartfelt messages•Have you completed the elevator message. •Are people buying in and telling you it is a good idea.

Action Taken:•Provide Regular Communication to Director and state and local level implementation teams•Update on PMTO regularly at conferences•Need to plan press releases•Readiness ChecklistBehavior Observed:•PMTO discussed at committee meetings

Test: •Do you provide timely communication to superiors?•Is it simple short and heartfelt?•Do you discuss the vision and strategies in regularly scheduled team meetings?

Communicated the Change Plan

Action: Empower action:•Leadership has to be willing to remove barriers to action •Leadership has to give a strong dose of empowerment to support the initiative •Key obstacles have to be removed.Behavior to observe:•More people fell able to act and do act on the vision. 

Action Taken:•Strong leadership from MDCH and CMH’s has helped lead the change•Providing leadership trainingBehavior Observed:•Leadership continues to plan for & support change

Test:•You observe recognition and reward systems that inspire and promote change•Supervisors are actively trying to remove barriers, change behavior, and build self confidence•New ideas are being proposed and tested

Empower Action Lead-Lead-Lead

Leading Change on a Good Day

Leading Change on a Bad Day

Action: Short term Wins •Identify and accomplish short-term wins. These provide credibility, resources, and momentum for the effort.•Guards against the cynics and skeptics.

Behavior to observe: •Momentum builds from short- term wins and fewer resist change.

Action Taken:•Identified additional funding to support local leadership teams.•Providing PMTO Training •Providing Leadership TrainingBehavior Observed:Training Provided

Test:•You can observe quick results that are made visible to all.•Leaders use quick results to demonstrate progress and share with others •People recognize and celebrate success•People want to be part of the change effort

Short Term Wins

Short Term Wins Make Change Easier

Action: Don’t let up:•Push for wave of change after wave of change until done. •Don’t let up, don’t quit too soon and don’t get bogged down. Behavior to observe: •People get on board and go with wave after wave of change and start surfing

Action Taken:•PMTO training initiated•G1,G2,G3•Leadership training initiated •Federal grants awarded   Behavior Observed:•Staff enjoy the training•New leaders are developing

Test:•Are new projects being launched?•Are leaders seeking new situations to further change effort?•Are leaders seeking to end the initiative too soon?•Evaluation results are being shared to support more change.

Wave of Change after Wave of Change

Action: Making change stick:•Create a new culture to make the new behavior stick•Nurture the new group norms and behavior through recognition, promotions, etc. Behavior to observe: New and willing behavior continues despite pulls backward. Change sticks

Action Taken:•Staff compare old outcomes to new outcomes.•Researching new ways to fund evidence based practices

Behavior Observed:

Test:•Are people seeking to understand what they need to do to fit in with the new environment?•Do people use old habits, “ways of being,” to describe the new way of being?•Are change leaders gaining more influence in the organization?

Creating a New Culture

10

10

10