Effland, Vicki Sprague

McIntyre, Janet S.

Walton, Betty A.

IUPUIScholarWorks

 Volume 8, Issue 2 March 2010 Systems of Care, Wraparound and Outcomes  By: Vicki Effland, Janet McIntyre and Betty Walton   During the past several years, Indiana has implemented several tools that have expanded our ability to measure youth and family outcomes (e.g., the CANS) and understand the processes that are associated with positive outcomes.  Recently, Vicki Effland, Ph.D., and Janet McIntyre from the Choices TA Center partnered with Betty Walton, Ph.D. to examine the relationship between the level of system of care development, wraparound fidelity and youth and family outcomes.  This study has been submitted for publication and accepted as a symposium at the 23rd Annual Children’s Mental Health Research & Policy Conference on March 7-10, 2010 in Tampa, Florida.  The data used in this study was collected during regular site visits by the Choices TA Center and through the ongoing evaluation of the Community Alternatives to Psychiatric Residential Treatment Facilities (CA-PRTF) demonstration grant.  To set the stage for this study, the authors use the framework developed by the National Implementation Research Network (NIRN) to describe the implementation of wraparound through systems of care (SOC) in Indiana. Specifically, Dean Fixsen and his colleagues (2005) identified five components of successful implementation: sphere of influence, source, destination, communication link and feedback. Dr. Effland and her colleagues defined each of these in the context of Indiana.  The sphere of influence was the fiscal and philosophical shift in the mid 1990’s to a belief in the potential for community based care for challenging youth, and the funding mechanism (MRO) to pay for coordinated care.  The source was provided by a few ground breaking Indiana communities that began implementing wraparound on their own, as well as two, six-year federal system of care grants in 1999.  The extensive evaluations associated with the federal grants helped convince policy makers that wraparound delivered through collaborative and coordinated systems of care could provide a cost effective alternative to expensive out of home care.  The destination or agency that provided the support – structural, philosophical and fiscal - for the implementation of wraparound through SOC was FSSA’s Division of Mental Health and Addiction.  The communication link (also called purveyor ) was the entity that provided information so that the adopters of wraparound through SOC implemented the “innovation” (that is, wraparound) with fidelity. In Indiana this link has been through intensive coaching, training and peer support provided or facilitated by Choices TA Center since 2002.   The final critical component was the provision of a feedback mechanism to inform all involved of their progress in the process of implementation.   Within this implementation context, three primary tools were used to assess the relationships between system of care development, wraparound fidelity and outcomes.  First, the Strengths-Based Site Assessment* is completed by TA Center site coaches with each community that is implementing wraparound in Indiana.  The site assessment includes a series of ratings to indicate the level of SOC development based on the first four stages of development described in the NIRN framework: exploration and adoption (stages 1 and 2), program installation (stage 3), initial implementation (stage 4) and full operation (stage 5).   Second, as part of the CA-PRTF grant evaluation, Wraparound Fidelity Index (WFI)* interviews were conducted with wraparound facilitators, caregivers and youth.  Total WFI scores were used to determine whether youth received services in one of four levels of wraparound fidelity (not wraparound, borderline, adequate and high).  The percent of youth receiving these four levels of wraparound was identified for communities within each of the four levels of system development. A higher percentage of youth were rated as receiving high fidelity wraparound in communities in Stages 4 and 5 than those in earlier stages of implementation (see Figure 1). This supports the importance of having well developed systems of care to support wraparound and shows that SOC in Indiana provides the necessary support for the implementation of high fidelity wraparound.   Figure 1  Third, the researchers used the WFI and the CANS to examine the relationship between wraparound fidelity and youth and family outcomes.  Specifically, the number of youth who demonstrated a reliable improvement in functioning between the time of their enrollment and discharge from CA-PRTF was identified for each of the four levels of wraparound.  The results indicated that youth who received high fidelity wraparound were more likely to have improved outcomes on the CANS (see Figure 2).   Figure 2   Why does this study matter? Because once again, we are reminded that solid data can give us a roadmap that leads to better outcomes for the children/youth and families we serve. It appears from this preliminary study that we are on the right road, going in the right direction!  Stay tuned to learn if future course corrections are needed….   *If you are not familiar with these tools, feel free to contact the TA Center at TACenter@ChoicesTeam.org for a more complete explanation of what they are and how they are administered. 

Systems of Care: Wraparound and Outcomes

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Systems of Care: Wraparound and Outcomes

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