john s. lyons, ph.d. university of ottawa/cheo northwestern university

Shaping our Future byManaging the business of

helping children and families:

It’s about change

John S. Lyons, Ph.D.University of Ottawa/CHEONorthwestern University

Key talking points

The child serving system has been systematically destroying itself by managing the wrong business. It is not a service, it is a transformational offering.

It is possible to manage transformations but this is radically different than managing services.

It is hard to shift to transformation management, but it is possible if we can all commit to trying to work differently.

Fundamentally, this process is about restoring trust in the system

Understanding the Business of Residential Treatment: The Hierarchy of Offerings

I. CommoditiesII. ProductsIII. ServicesIV. ExperiencesV. Transformations

- Gilmore & Pine, 1997

Problems with Managing Services

Find people and get them to show up Assessment exists to justify service receipt Manage staff productivity (case loads) Incentives support treating the least

challenging youth. Supervision as the compliance

enforcerment An hour is an hour. A day is a day System management is about doing the

same thing as cheaply as possible.

How Transformation Management is Different

Find people you can help, help them and then find some one else

Accuracy is advocacy. Assessment communicate important information about the people we serve

Impact (workload) more important that productivity

Incentives to treat the most challenging youth. Supervision as teaching Time early in a treatment episodes is more

valuable than time later. System management is about maximizing

effectiveness of the overall system

Next Problem. How do you engineer effectiveness?

Because of our service management mentality the lowest paid, least experienced people spend the most time with our youth and families.

Need to take collective wisdom and somehow help young staff get up to speed on being effective really fast.

Pilots don’t fly planes anymore. Planes fly themselves. Is there a lesson there for us?

Third problem. Where’s the love? Have we lost faith in each other caring about our youth and families?

Many different adults in the lives of the children we serve

Each has a different perspective and, therefore, different agendas, goals, and objectives

Honest people, honestly representing different perspectives will disagree

This creates inevitable conflict. In residential treatment, this reality has

created a significant amount of distrust

Restoring Trust—the essential outcome of conflict management

Different perspectives cause inevitable conflict. Resolving those perspectives requires conflict resolution strategies.

There are two key principles to effective conflict resolution There must be a shared vision There must be a strategy for creating

and communicating that shared vision

Core Concepts of Transformation Management

We need to create and communicate a shared vision that is about wellbeing of our children and families. This shared vision has to involve the participation of all key partners in order to restore trust.

We need to use that information to make good decisions about having an impact (rather than spending time and space with youth). This information must be used simultaneously at all levels of the system to ensure that we are all working towards the same goals.

This is not going to be easy.

The Philsophy: Total Clinical Outcomes Management (TCOM)

Total means that it is embedded in all activities with individual & families as full partners.

Clinical means the focus is on child and family health, well-being, and functioning.

Outcomes means the measures are relevant to decisions about approach or proposed impact of interventions.

Management means that this information is used in all aspects of managing the system from individual family planning to supervision to program and system operations.

Managing Tension is the Key to Creating an Effective System of Care

Philosophy—always return to the shared vision. In the mental health system the shared vision are the children and families

Strategy—represent the shared vision and communicate it throughout the system with a standard language/assessment

Tactics—activities that promote the philosophy at all the levels of the system simultaneously

Why I don’t think traditional measurement approaches help us manage transformations

Most measures are developed from a research tradition. Researchers want to know a lot about a little. Agents of change need to know a little about a lot. Lots of questions to measure one thing.

Traditional measurement is arbitrary. You don’t really know what the number means even if you norm your measures.

Traditional measurement confounds interventions, culture and development and become irrelevant or biases. You have to contextualize the understanding of a person in their environment to have meaningful information.

Triangulation occurs post measurement which is likely impossible.

The Strategy: CANS and FASTSix Key Characteristics of a Communimetric Tool

Items are included because they might impact care planning

Level of items translate immediately into action levels

It is about the child not about the child in care

Consider culture and development It is agnostic as to etiology—it is

about the ‘what’ not about the ‘why’ The 30 day window is to remind us to

keep assessments relevant and ‘fresh’

Family & Youth Program System

Decision Support

Care PlanningEffective practices

EBP’s

EligibilityStep-down

Resource ManagementRight-sizing

Outcome Monitoring

Service Transitions & Celebrations

Evaluation Provider ProfilesPerformance/ Contracting

Quality Improvement

Case ManagementIntegrated Care

Supervision

CQI/QAAccreditation

Program Redesign

TransformationBusiness Model

Design

TCOM Grid of Tactics

Survival analysis of time to placement disruption for children/youth whose placement matches CANS recommendations (Match=0), those whose placed is at a lower intensity than recommended (match=1) and those whose placement is more intensive than recommended (match=-1).

Figure 3. Comparison of Life Domain Functioning between CANS/CAYIT agreed referrals to residential treatment (Concordant)

and CANS referrals to lower levels of care who were placed in residential treatment (Discordant)

18.54

14.1013.22

14.98

12.8511.50

0

2

4

6

8

10

12

14

16

18

20

CAYIT CANS (p<.01) 1st Residential CANS 3-6 Mo. ResidentialCANS (p<.05)

Concordance

Discordance

Figure 2. Trauma Symptoms comparison between CANS/CAYIT agreed referrals to residential treatment and CANS referrals to lower levels of care who were placed in residential treatment (Discordant)

5.39

4.76

3.734.15

4.77

4.66

0

1

2

3

4

5

6

CAYIT CANS (p<.01) 1st Residential CANS 3-6 Mo. ResidentialCANS

Concordance

Discordance

Figure 4. Comparison of Emotional/Behavioral Needs between CANS/CAYIT agreed placements in residential treatment

(Concordant) and CANS referrals to lower levels of care who were placed in residential treatment (Discordant)

16.11

13.34 12.91

12.32 12.6312.29

0

2

4

6

8

10

12

14

16

18

20

CAYIT CANS (p<.01) 1st Residential CANS 3-6 Mo. ResidentialCANS

Concordance

Discordance

Figure 1. Level of Need by Year for Admissions into Residential TreatmentN=2782

0

2

4

6

8

10

12

14

16

18

Beh/Emotion RiskBehaviors

Functioning Strengths

2003

2004

2005

2006

2007

Figure 6. Comparison of total score for RTC, CMO, and YCM initial assessments by year

0

5

10

15

20

25

30

35

40

2003 2004 2005 2006 2007

YCM

CMO

RTC

Figure 8. Average Improvement over the course of Residential Treatment by Year Note: higher score better improvement)

0

1

2

3

4

5

6

7

Beh/Emotion Risk Behavior Functioning

2003

2004

2005

2006

6

6.5

7

7.5

8

8.5

9

9.5

0 0.25 0.5 0.75 1 1.25 1.5 1.75 2

Year

TOT Scale

ALL YCM CMO TRH GRH PCR RES

Outcome Trajectories by program type in New Jersey

7

7.5

8

8.5

9

9.5

10

10.5

-1 -0.5 0 0.5 1 1.5 2

Years (vs Start Date)

Item

Ave

rage

(x

10)

TOT (ALL) YCM CMO TRH GRH PCR RES

Start

Hinge analysis of outcome trajectories prior to and after program initiation

Illinois Trajectories of Recovery before and after entering different types of Child Welfare Placements

5

6

7

8

9

10

11

-2 -1 0 1 2 3

Year

CA

NS

Ov

era

ll C

hil

d S

co

re

ALLILORFCFCSFCTLPGHRES

Percent of hospital admissions that were low risk by racial group Adapted from Rawal, et al, 2003

0%5%

10%15%20%25%

30%35%40%45%50%

1998 1999 2000 2001 2002

% o

f L

ow R

isk

Adm

issi

ons White

AfricanAmerican

Hispanic

Key Decision Support CSPI Indicators Sorted by Order of Importance in Predicting Psychiatric

Hospital Admission

If CSPI ItemRated as Start with 0 and

Suicide 2,3 Add 1

Judgment 2,3 Add 1

Danger to Others 2,3 Add 1

Depression 2,3 Add 1

Impulse/Hyperactivity 2,3 Add 1

Anger Control 3 Add 1

Psychosis 1,2,3 Add 1

Ratings of ‘2’ and ‘3’ are ‘actionable’ ratings, as compared to ratings of ‘0’ (no evidence) and ‘1’ (watchful waiting).

Change in Total CSPI Score by Intervention and Hospitalization Risk Level (FY06)

51.2

34.134.231.0

24.4

17.5

47.4

35.2

26.4

22.1 24.218.0

0

10

20

30

40

50

60

SASS Assessment End of SASSEpisode

Mea

n C

SP

I S

core

HOSP (high riskgroup)

ICT (high risk group)

HOSP (medium riskgroup)

ICT (medium riskgroup)

HOSP (low riskgroup)

ICT (low risk group)

Shifting to Transformational Management is not easy

To be successful we must learn to: embed shared vision approaches into the

treatment planning and supervision at the individual level

treat documentation with the same level of respect that we treat our youth and families

aggreggate and use this information to inform policy decisions

change financing structures to support transformation management, not service receipt.

trust each other