enhancing wraparound with evidence based practices using...

Enhancing Wraparound with Evidence Based Practices Using the Managing and Adapting

Practice (MAP) System Eric J. Bruns, Ph.D.

University of Washington School of Medicine, Seattle, WA

Eric Daleiden, Ph.D. and Bruce Chorpita, Ph.D. PracticeWise, LLC

26th Annual Research and Policy Conference on Children’s Mental Health

Tampa, FL March 4, 2013

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Thanks to the Institute for Innovation and Implementation at the University of Maryland School of Social Work for their partnership in development work and to Catholic Community Services of

Western Washington for their participation in the pilot testing of the Wrap + MAP idea.

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Research to Date on Wraparound

• There have been 9 controlled studies of wraparound published in peer review journals

• Results consistently indicate superior outcomes for wraparound compared to “services as usual”* – Moderate (ES = .50) effects for living situation and

community (e.g., recidivism, school attendance) outcomes

– Smaller (ES = .25 - .30) effects for behavioral, functional, and clinical outcomes

*Suter, J.C. & Bruns, E.J. (2009). Effectiveness of the Wraparound Process for Children with Emotional

and Behavioral Disorders: A Meta-Analysis. Clinical Child and Family Psychology Review, 12, 336-351

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Research to Date on Wraparound

• However: – Evaluations have shown better outcomes for alternative conditions,

when connected to effective clinical care (Bruns et al., in revision) – Study comparing Wrap to MST (Stambaugh et al., 2007) found:

• Wrap addressed the needs of more youths in the system and similar functional outcomes, but

• Better clinical outcomes for MST and shorter length of intervention for MST

• Implication: The lack of specificity about how to use research evidence in wraparound may reduce – Clinical/functional effectiveness – Efficiency – Family and team member perception of quality of options

*Suter, J.C. & Bruns, E.J. (2009). Effectiveness of the Wraparound Process for Children with Emotional

and Behavioral Disorders: A Meta-Analysis. Clinical Child and Family Psychology Review, 12, 336-351

A call to action

• “It is time to finally develop and test a model in which the community based strengths and potent delivery systems of wraparound are united with the empirical strength of evidence-based interventions, to promote and protect mental health in children and their families”

– John Weisz et al., The American Psychologist (p.645).

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Big ideas to Enhance Wraparound

1. Generate evidence based strategies that fit the youth and family’s needs during the wraparound planning process

2. Support clinicians to use effective practices that connect to the youth and family’s priority needs

3. Coordinate family and youth partners, mentors, and other allies to support appropriate EBP use

4. Monitor progress and practice more consistently and change plans as needed

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Big Ideas Proposed enhancement Mechanisms for achieving Hypothesized effects Generate evidence based strategies that fit the youth and family’s needs during planning and delivery

Support clinicians to use effective therapies that connect to the youth and family’s priority needs

Individuals serving in peer, community, natural support roles have poorly defined roles or are not engaged at all

Monitor progress and practice more consistently and change plans as needed

Big ideas to Enhance Wraparound

The question is: HOW?

What is an approach to EBP that

would work for wraparound?

The MAP Proposal: Organize EBP into a Knowledge Management Approach

See the evidence base as knowledge and not simply products…

Organize libraries of common practices and processes with empirical support

Build information resources and tools

Coordinate delivery systems to support practitioners to generate ideas for addressing perennial questions with the “best evidence” and to self-correct over time

Why might this work? • Identified practices will fit wraparound youths (RMAP;

Bernstein et al., 2013)

• A state that tried a version of this showed better outcomes (HI; Daleiden et al., 2006)

• MAP can “go to scale” and yield positive outcomes (LA; Southam-Gerow et al., 2013)

• Modular EBP yielded better progress than standard EBT and usual care in a RCT (MATCH; Weisz et al., 2012)

• Knowledge and use of support practices is associated with better treatment quality in school-based services (SMH; Stephan et al., 2012)

• Supported practices predict progress better within a coordinated service model (MST; Denneny & Mueller, 2012)

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Use MAP tools to generate a broader array of research-based options that fit the youth and family’s needs


When therapeutic needs are identified, ensure clinicians use effective treatment elements that connect to the youth and family’s strengths and preferences


Parent and youth partners, mentors, behavioral specialists, and others serve as “care extenders,” provide appropriate follow-on support to treatment strategies


Use a structured tool to monitor progress and practices consistently and use the information to revise plans as needed

What are the MAP tools

and resources?

Getting down to the building blocks of

“what works”

Incredible

Years PCIT

Defiant

Children

Parent Training

Commands Commands Attending

Time Out

Rewards

Time Out

Protocols

Families

Practice Elements

Managing and Adapting Practice (MAP)

• Three main innovations:

– PracticeWise Evidence Based Services (PWEBS) Database • Method for a practitioner to use the database of common treatment

elements

– Practitioner Guides • Codified clinical supports

– Clinical Dashboard • Feedback tool to monitor process and progress of treatment

– Supported by an on-line resource library and user interface called PracticeWise (www.practicewise.com)

This tells you the practice elements associated with those treatment types.

Objectives:

to increase the amount of positive attention provided to the child, even if the child has misbehaved at other times during the day

to teach the caregiver to attend to positive behaviors

to promote the child’s sense of self-worth

Steps:

Provide rationale Emphasize the importance of providing positive attention to the child.

Elicit the caregiver’s opinion about how attention affects behavior and people’s motivation to do a good job.

Have the caregiver describe his or her best and worst “managers” and the caregiver’s motivation to work for each.

Lead the caregiver to recognize that how he or she was treated affected the caregiver’s desire to work.

Discuss how the child’s behavior may be affected by the caregiver’s behavior towards the child and how the child’s desire to behave can be increased by improving the caregiver-child relationship.

Set aside one-on-one time for caregiver and child

Encourage the caregiver to set aside a block of time (e.g., 10 minutes) each day devoted to joining the child in an activity the child has chosen.

Teach caregiver to provide positive and descriptive commentary

Show the caregiver how to demonstrate sincere interest in the child’s activities while they are playing.

Instruct the caregiver to provide enthusiastic descriptive (e.g., “You are drawing a tree”) and/or positive (e.g., “I like the way you stacked the blocks”) commentary and praise regarding the child’s behavior.

Encourage caregiver to engage in child’s activity

Suggest that the caregiver become actively involved in the play activity by imitating the child’s behavior in order to demonstrate approval.

Restrict criticism, questions, and commands

It is important that the child lead the activity; that is, the caregiver should refrain from making suggestions, asking questions, and criticizing the child.

Allow the child to use his or her imagination (e.g., coloring the green or making up new rules to a game) without caregiver input about the “correct” way to do things.

Anticipate difficulties When the procedure is initially implemented, the child may engage in negative behavior that characterizes the usual caregiver-child interaction. When this occurs, the caregiver should:

consistently ignore negative behavior by looking away;

refrain from scolding the child so as to avoid providing negative attention for misbehavior;

end one-to-one time if disruptive behavior continues or is dangerous.

Over time, however, it is expected that consistent positive attending will result in decreased negative behavior and increased positive caregiver-child interactions.

Attending

Use This When:

To improve the quality of the caregiver-child relationship.

Practitioner Guide

For CaretakerFor Caretaker

One 2-sided page per practice

During Session Before Session

Remind client and obtain commitment

Review dashboard to assess progress and practice history

Review notes on previously assigned homework

Identify next practice(s) that will be the focus

Review the Practice Guide(s)

Establish session plan and choose rehearsal activity

Check in with supervisor if needed

After Session Record progress

ratings and practice(s) performed

Review Practice Guide(s) to determine if any steps were missed that should be covered next time

Note any homework that was assigned

Note any new stressors or obstacles

Check in with supervisor if needed

The Session Planner (Clinical Event Structure)

Process

Guide

© 2012 PracticeWise, LLC

Opening

• Check In, Identify a Strength

• Review Earlier Skills/Homework

• Set Agenda

Working

• Advise, Instruct, Or Guide

• Rehearse

• Repeat

Closing

• Review

• Assign Homework

• Reward

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• Use PWEBS searches at strategic points in planning process

• Use Practice Guides to help family and team members understand options



• Train and coach wraparound-affiliated clinicians on MAP system and treatment elements

• Certify clinicians in MAP



• Modify select MAP treatment elements to “care extension” strategies

• Orient/train support staff in care extender model

• Clinicians/team include follow-on support strategies in wraparound plans



• Facilitators trained to use team-level dashboard

• Clinicians trained to use MAP clinical dashboard

• Supervisors trained to use dashboards in supervision

What will

this do?

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• Use PWEBS searches at strategic points in planning process

• Use Practice Guides to help family and team members understand options

• Greater range of options for family/team

• Options are based on evidence for effectiveness

• Family/team better engaged, more hopeful, more satisfied



• Train and coach wraparound-affiliated clinicians on MAP system and treatment elements

• Certify clinicians in MAP

• Treatments better fit youth clinical needs

• Better communication with wraparound team about purpose of therapy

• Treatments more focused • Treatments more effective



• Modify select MAP treatment elements to “care extension” strategies

• Orient/train support staff in care extender model

• Clinicians/team include follow-on support strategies in wraparound plans

• Better role definition for persons in support roles

• More effective teamwork • Treatment strategies more

effective • Support staff more satisfied

and show greater self-efficacy



• Facilitators trained to use team-level dashboard

• Clinicians trained to use MAP clinical dashboard

• Supervisors trained to use dashboards in supervision

• More frequent progress review • Better teamwork/problem

solving • Shorter self-correction cycles • Understanding of transition • Shorter wraparound episodes

One Idea = Ensure connection to a

MAP Therapist


Wrap Facilitator

…as well as…

Parent Partner

Youth Specialist

MAP Therapist

Clinical

Dashboard

Codified

Clinical

Procedures (PG)

Service Literature

(PWEBS)

Biger idea:

Fully coordinated process


Wrap Facilitator

…as well as…

Parent Partner

Youth Specialist

MAP Therapist

Plan of Care

Clinical

Dashboard

Team Meeting

Codified

Procedures (PG)

Service Literature

(PWEBS)

Family/Collateral

Communication

Direct

Communication

Initial response is encouraging

• 88% of MAP therapists who work in wraparound contexts agreed combining Wrap and MAP would promote positive outcomes

• 90% of wraparound providers (N=21) in our pilot site “agreed” or “strongly agreed” that combining Wrap and MAP would promote positive outcomes

• 88% of wraparound facilitators and family peer support partners who used PWEBS to facilitate plan development agreed that it improved the options available to planning

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General

Services

Research

Local

and Community

Evidence

Family Story

and Timeline

Causal

Mechanism

Research

Priority

Needs &

Goals

Strategies,

Supports, and

Treatments

Service

Setting

Client

Progress

Treatment

Integrity

MAP Therapist

Resources

& Supports

Wraparound

Team/

Process

Wraparound

Facilitator

•Engagement

•Teamwork

•Goal Setting

•Integrated Plan

of Care

•Collateral

Communication

•Social Support

Satisfaction

and Wrap

Fidelity

•Service

Literature

•Searchable

Database

•Codified

Procedures

•Clinical

Dashboard

Peer Support

Worker

Evidence-based Wraparound Care Coordination

Model?

Adapted with Permission from EBS System Model, © 2012 PracticeWise, LLC

Next steps

• Preparation for pilot test:

– Developing MAP training content for individuals in wraparound roles

– Adapting training on relevant treatment elements to care extenders (e.g., peer supports, mentors, behavioral support specialists)

– Developing wraparound team-level progress and practice dashboard

• Tests of feasibility, parent and provider perceptions, and teamwork outcomes

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For more information

• PracticeWise: www.practicewise.com

• Wraparound Evaluation and Research Team: www.wrapinfo.org

• Eric Bruns: [email protected]

• Eric Daleiden: [email protected]

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http://www.practicewise.com/

http://www.wrapinfo.org/

mailto:[email protected]

mailto:[email protected]

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