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The Child and Adolescent Needs and Strengths (CANS) is a multi-purpose tool developed for children’s services to support decision making, including level of care and service planning, to facilitate quality improvement initiatives, and to allow for the monitoring of outcomes of services.
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Abram Rosenblatt, Ph.D.EMQ FamiliesFirst
Presentation OverviewContextEBP’sMeasurementGapsExampleConclusions
Service Systems Are ComplexPracticeProgramSystem
Impact is ComplexEffectivenessEfficiencyEquity
Setting the Stage: A FrameworkSystem Goals
Practice Level Program Level System Level
Effectiveness The effect of a clinical intervention on outcomes
The effect of program philosophy/culture on outcomes
The effect of standards of care, service provision, and/or funding on outcomes
Efficiency The effect of provider productivity on costs
The effects of staffing choices, provider mix, and/or work hours on costs
The effect of fiscal incentives, service system integration, and/or service mix on costs
Equity The effect of provider choice and decision making on disparities
The effect of program location and accessibility on disparities
The effect of program mix and/or fiscal incentives on disparities
Purposes of Collecting Data and Perceived Value
Setting the Stage: TrendsSystems of Care
System Focus? Efficiency and Equity Impacts Effectiveness unclear
Wraparound Mostly Program, also practice and system Fidelity Effectiveness…maybe
Evidence Based Practice Practice, also program Effectiveness
The Current Star: EBP’sMore Effective than Usual Care
Don’t know a lot about “usual care”Arbitrary Metrics ProblemReplication ConcernsTransportability and Drift
Equity?Iatrogenic potential at system level
Efficiency?Cost Effectiveness usually unknown
EBP Alphabet SoupMandate for EBP’s and Motivation to select most
effective services creates challengesEMQ FF EBP Implementation (Partial List)
PCITIncredible YearsTriple PTF-CBTACRABSFTACTFFT
Where to Go?Outcomes Management
TCOMMeasurement Feedback SystemsResults Based AccountabilityClinical Dashboards
Common Elements Approaches MAP/Child STEPS
Quality of Care
Turbulence AheadCounty or project specific Outcome
RequirementsEBP Measurement RequirementsOver 30 Different Measures used at EMQ FF,
most of which can not be changed or consolidated
Multiple Measures and PerspectivesThe Importance of ValuesRapidly changing economic and funding
landscapeHealth Care Reform
What to do? An Example from One AgencyStrong History of WraparoundIntensive EBP implementationStrong Commitment to Outcomes and
EvaluationMultiple Counties and RegionsStrong ValuesFoster Care and Mental Health
Addressing GapsAssessmentOutcomes Management/Measurement
FeedbackStrategic Use of Evidence Based PracticeOverall Clinical Competencies and SkillsOutcome data collection across all programs
Evolution Values
Assessment and Outcomes: Child and Adolescent Needs and Strengths (CANS)Clinician Based Rating ScaleParent and Child Perspectives?Mental Health Assessment
SymptomsDiagnosis
Real World ReferentsIn HomeIn SchoolOut of Trouble
Clinical Skills: Development Needs“Usual Care” not as effective and beneficial
as Evidence Based PracticesMany EBPs already in place at EMQ FF and
no strategic plan for EBP implementationEBPs do not exist for all clinical situationsEMQ FF serves youth who do not match
existing EBPs EBPs costly and labor intensiveSome clinical staff at EMQ FF are not
qualified for some EBP trainings
Use EBPs Efficiently and Effectively: Relevance Mapping
Can create a guideline for EBP implementation at EMQ FF based on existing data
Includes: Presenting problem or diagnosis Age Gender Ethnicity Setting
Allow for a more rational approach to determining EBP implementation at EMQ FF and more efficient resource allocation given high cost of most EBP’s.
Examples from Relevance MappingSeventy six percent (71%) of youth are covered by at least ‐
one evidence based treatment that applies to their primary ‐problem, age group, and gender.
About half of youth with attention/hyperactivity problems are above the tested age range for evidence based treatments.‐
Aside from treatments developed for disruptive behavior, many evidence based treatments are less often tested in ‐settings typical of the service model.
Cognitive Behavior Therapy alone applies to 61% of all youth—almost all of the youth coverable by any evidence based ‐practice.
Core Clinical Skills: Managing and Adapting Practice (MAP)Common Elements Approach: Effective
services from high quality partsMatch practice elements to specific clinical
scenariosPractice elements based on extensive review of
existing literature (“Evidence Based” practice elements)
Practice Wise Data BaseHelps select practice elementsHelps select EBP’s if appropriate
Clinical DashboardFeedback on selected outcomes
Creating an Integrated Clinical ModelStandard Assessment with the CANSEfficient and Effective planning for EBP
implementation with relevance mappingCore clinical skill development with the Common
Elements ApproachUse of the CANS to enhance selection of
appropriate common elements or EBPs at the clinical level
Clinical Quality Improvement with the Clinical Dashboard using the CANS as core measure
Development and refinement of current practices at EMQ FF
Integrated Model: CANS and Relevance MappingCANS for Assessment and Outcomes Tracking
Assists in EBP implementationAssists in “common elements” selectionCore component of Clinical Dashboard trackingAssists in level of care determinations
EBP Relevance mapping Empirically map potential EBP’s to young people
servedAppropriate use of EBP’sShows where common elements approach is most
neededDemonstrates where novel program development is
most needed
Integrated Model: Baseline Clinical Skills and Clinical CQIMAP model
Assures baseline clinical competenciesApplies to young people and families for whom
EBPs are not relevantApplies to young people and families for whom
EBPs can not be provided Helps guide EBP selection by clinical staffHelps provide continuous quality improvement
at the clinical levelIntegrate with CANS
AdvantagesStandardization of assessmentStandardization of core clinical competenciesApplicable to most or all young people and
families served at EMQ FFCompatible with existing servicesDoes NOT replace existing clinical skill sets and
judgmentEfficient and effective use of costly service
optionsEnhances clinical workforce developmentEmpirically based and “state of the art”
Conclusion: Moving the CANS to Center StageAssessment
Replace EBP measures?Outcomes
Usual Care?EBP Relative Effectiveness
Measurement FeedbackEBP planningCommon Elements SelectionQuality of Care