Acknowledgements Acknowledgements Richard Hibbert, MSW, Myla - - PDF document

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Engaging families and engaging Engaging families and engaging Engaging families and engaging Engaging families and engaging services services

Presented by Presented by M M K PhD M M K PhD Mary McKay, PhD Mary McKay, PhD Mount Sinai School of Medicine Mount Sinai School of Medicine

Acknowledgements Acknowledgements

Richard Hibbert, MSW, Myla Harrison, M.D., Richard Hibbert, MSW, Myla Harrison, M.D., A th S l Ph D CHAMP A th S l Ph D CHAMP Anthony Salerno, Ph.D., CHAMP Anthony Salerno, Ph.D., CHAMP collaborators collaborators New York State Office of Mental Health & New York State Office of Mental Health & National Institute of Mental Health National Institute of Mental Health National Institute of Mental Health National Institute of Mental Health

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Welcome and Introductions Welcome and Introductions

 Identify 1 obstacle that you have

Identify 1 obstacle that you have encountered as you tried to involve encountered as you tried to involve youth and their families in services. youth and their families in services.

Mental Health and Children Mental Health and Children

 Two thirds of children in need of mental

Two thirds of children in need of mental h lth d t i i h lth d t i i health care do not receive services. health care do not receive services.

 No show rates can be as high as 50%.

No show rates can be as high as 50%.

 Drop outs occurring after two or three

Drop outs occurring after two or three sessions are common. sessions are common.

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The Research: Barriers to Involvement in The Research: Barriers to Involvement in Child Mental Health Interventions (Urban Child Mental Health Interventions (Urban Settings) Settings)

 Triple threat: poverty, single parent status

Triple threat: poverty, single parent status d t d t and stress and stress

 Concrete obstacles: time, transportation,

Concrete obstacles: time, transportation, child care, competing priorities child care, competing priorities

 Attitudes about mental health, stigma

Attitudes about mental health, stigma

 Previous negative experiences with mental

Previous negative experiences with mental

 Previous negative experiences with mental

Previous negative experiences with mental health or institutions health or institutions

The Research: Barriers to Involvement in The Research: Barriers to Involvement in Child Mental Health Interventions (Rural Child Mental Health Interventions (Rural Settings) Settings)

 Scarce mental health resources

Scarce mental health resources

 Transportation

Transportation

 Stigma associated with mental illness and

Stigma associated with mental illness and seeking care seeking care

 Concerns about confidentiality

Concerns about confidentiality l l

 Isolation

Isolation

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Empirically supported Engagement Empirically supported Engagement Interventions Interventions

 Focused telephone procedures associated

Focused telephone procedures associated ith i d i iti l h t ith i d i iti l h t with increased initial show rates with increased initial show rates

 Structural family therapy telephone

Structural family therapy telephone engagement intervention associated with engagement intervention associated with 50% decrease in initial no show rates and 50% decrease in initial no show rates and a 24% decrease in premature terminations a 24% decrease in premature terminations a 24% decrease in premature terminations a 24% decrease in premature terminations (Szapocznik, 1988; 1997; 2004) (Szapocznik, 1988; 1997; 2004)

Summary: Summary: Telephone

Telephone E t St t i t E t St t i t Engagement Strategies to Engagement Strategies to Address Barriers Address Barriers

“First Telephone “First Telephone p Contact” Contact”

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Telephone Engagement Telephone Engagement Intervention Intervention

 Intervention during the initial telephone

Intervention during the initial telephone i t k i t t ll i t k i t t ll intake or appointment call intake or appointment call

 Relies on an understanding of child,

Relies on an understanding of child, family, community and system level family, community and system level barriers to mental health care barriers to mental health care

 Goals:

Goals:

 Goals:

Goals: 1) clarify the need for mental health care 1) clarify the need for mental health care 2) increase caregiver investment and 2) increase caregiver investment and efficacy efficacy

Telephone Engagement Telephone Engagement Intervention (cont.) Intervention (cont.)

 Goals:

Goals: 3) Identify attitudes about previous 3) Identify attitudes about previous experiences with mental health care and experiences with mental health care and institutions institutions 4) PROBLEM SOLVE! PROBLEM SOLVE! 4) PROBLEM SOLVE! PROBLEM SOLVE! PROBLEM SOLVE! around concrete PROBLEM SOLVE! around concrete PROBLEM SOLVE! around concrete PROBLEM SOLVE! around concrete

• bstacles to care
• bstacles to care

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What needs to happen on the What needs to happen on the telephone? telephone?

R f l t t t t R f l t t t t

 Referral to treatment

Referral to treatment

– Help parents invest Help parents invest initially in treatment initially in treatment for their child for their child – Help parents and child Help parents and child invest in ongoing work invest in ongoing work with provider with provider – Problem Solving! Problem Solving! Problem Solving! Problem Solving!

Clarify needs of child and Clarify needs of child and family family

 Perception of concern

Perception of concern

– How Long How Long

 Perception of services

Perception of services and “helpers” and “helpers”

• g
• g

– Where Where – – at home at home – – at at school school – – with friends with friends-

• with other adults

with other adults

and helpers and helpers

– Relationship with Relationship with teachers teachers – Previous therapy Previous therapy experiences (either kids experiences (either kids

• r adults)
• r adults)

– Previous experience with Previous experience with p helping providers helping providers

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Needs of the child and family Needs of the child and family (cont.) (cont.)

 Defining concern

Defining concern

Recent example Recent example  Getting help

Getting help

Can services make a Can services make a – Recent example Recent example – Why now Why now – Strengths in Strengths in supporting child supporting child – Things parent has Things parent has tried in the past tried in the past – – Can services make a Can services make a difference for the difference for the child child – Have they sought Have they sought help before help before – Was that experience Was that experience h l f l h h l f l h helpful; was the helpful; was the provider helpful provider helpful

Getting ready for the appointment: Getting ready for the appointment:

Assignments for the Caretaker & Appointment Assignments for the Caretaker & Appointment Scheduled Scheduled

 Make a list of:

Make a list of:

• Strengths

Strengths

• Strengths

Strengths

• Goals

Goals

• Concerns

Concerns

• Discuss coming to the appointment with

Discuss coming to the appointment with your child. your child.

• Time
• Date
• Intake Worker
• Address
• Directions by car, bus, and subway

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Basics of Active Problem Solving Basics of Active Problem Solving

 What do you think about coming?

What do you think about coming?

 What could stand in the way of getting here?

What could stand in the way of getting here?

 What could stand in the way of getting here?

What could stand in the way of getting here?

 How are you going to get here?

How are you going to get here?

 Who are you going to bring?

Who are you going to bring?

 How will these people feel about coming?

How will these people feel about coming?

Basics of Active Problem Solving Basics of Active Problem Solving

 What time is best for you?

What time is best for you? ll h f h h l ll h f h h l

 Will this interfere with anything else?

Will this interfere with anything else?

 How comfortable do you feel talking about your

How comfortable do you feel talking about your child’s needs? child’s needs?

 How hopeful do you feel that this will help?

How hopeful do you feel that this will help?

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Preparation for the first meeting is Preparation for the first meeting is key! key!

 Getting ready for the first

Getting ready for the first meeting meeting

– Meet with our staff to get a Meet with our staff to get a better idea of how (facility, better idea of how (facility, treatment, services) can be treatment, services) can be helpful. helpful. – Will spend some time filling Will spend some time filling

• ut forms (i.e. insurance,
• ut forms (i.e. insurance,

basic info, etc.) basic info, etc.) – Will spend more time talking Will spend more time talking Will spend more time talking Will spend more time talking with parent, child, and other with parent, child, and other family members so that we family members so that we can come up with a plan to can come up with a plan to help (child’s name). help (child’s name). – How does that sound? How does that sound?

Important considerations throughout Important considerations throughout the telephone interview the telephone interview

 Race

Race

 Ethnicity/cultural issues

Ethnicity/cultural issues

 Ethnicity/cultural issues

Ethnicity/cultural issues

 Stressors

Stressors

 Isolation

Isolation

 Fears that friends,

Fears that friends, neighbors will disapprove neighbors will disapprove

• f seeking care
• f seeking care

 Helping client manage in

Helping client manage in communities of scarce communities of scarce resources resources

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Telephone Engagement Study Telephone Engagement Study Methods Methods

 Outcome of interest: # of families that

Outcome of interest: # of families that t i iti l i t t t i iti l i t t came to an initial appointment came to an initial appointment

 Setting: outpatient child mental health

Setting: outpatient child mental health clinic clinic

 Sample:

Sample: n n= 54 = 54

 Design: Matched comparison of

Design: Matched comparison of

 Design: Matched comparison of

Design: Matched comparison of consecutive referrals in one month consecutive referrals in one month

Telephone Engagement Study Telephone Engagement Study Results Results

25 21 6 13 14 10 15 20 # of children brought to first session (n=27 per condition) no show 6 5 Engage Compare

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Telephone Engagement Study Telephone Engagement Study # 2 Methods # 2 Methods

 Outcome of interest:

Outcome of interest: # of families that # of families that t i iti l i t t t i iti l i t t came to an initial appointment came to an initial appointment

 Setting:

Setting: Outpatient child mental health Outpatient child mental health clinic clinic

 Sample:

Sample: n= 108 = 108

 Design:

Design: random assignment to condition random assignment to condition

 Design:

Design: random assignment to condition random assignment to condition

Telephone Engagement Study Telephone Engagement Study # 2 Results # 2 Results

40 40 15 24 29 10 15 20 25 30 35 # of families that came to 1st appt. No show 5 10 Engage Compare

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Exercise 1: Barriers to child/family Exercise 1: Barriers to child/family engaging in the helping process engaging in the helping process

Instructions for participants: p p

• List 5 – 10 obstacles that would prevent a child

from wanting to come to a treatment appointment.

• Next, list 5 – 10 obstacles that would interfere at

the parent/family level in getting to a treatment appointment.

• What new strategies can you develop to help

families address obstacles?

Exercise 2: What would make a families’ Exercise 2: What would make a families’ experience perfect at your site? experience perfect at your site?

Instructions for participants: Instructions for participants: Imagine you are a parent calling to get services at your agency for the first time. Describe what would make the experience perfect for that parent and

• child. Start your description with the phone call and

include your arrival to the agency waiting room but end at the point you are called to meet the intake worker.

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First Interview Engagement First Interview Engagement Strategy Strategy

Summary: Engagement Summary: Engagement Approach to Involving Approach to Involving Approach to Involving Approach to Involving Children and their Families Children and their Families

First Interview First Interview

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Vulnerable populations Vulnerable populations

 The most vulnerable child populations, in

The most vulnerable child populations, in t f i f ti t f i f ti terms of seriousness of presenting terms of seriousness of presenting problems or complexity of social problems or complexity of social situations, are less likely to be retained situations, are less likely to be retained beyond the 1 beyond the 1st

st mental health session

mental health session

 The delivery of services to vulnerable

The delivery of services to vulnerable client populations rests on the client populations rests on the engagement of clients in the helping engagement of clients in the helping process. process.

Vulnerable populations (cont.) Vulnerable populations (cont.)

 Therefore it is critical for interviewers to develop

Therefore it is critical for interviewers to develop and utilize focused culturally sensitive and utilize focused culturally sensitive and utilize focused culturally sensitive and utilize focused culturally sensitive engagement skills that address the range of engagement skills that address the range of barriers that can exist within families, barriers that can exist within families, environments, and agencies interfering with the environments, and agencies interfering with the process of engagement. process of engagement.

 A protocol for first/engagement interviews was

A protocol for first/engagement interviews was developed and tested with the following results. developed and tested with the following results.

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Purpose of first interview Purpose of first interview engagement strategy engagement strategy

 Two primary

Two primary purposes: purposes: purposes: purposes:

– To understand why a To understand why a child and family want child and family want help from provider. help from provider. – To engage the child To engage the child and family in a helping and family in a helping if i t if i t process, if appropriate. process, if appropriate.

Four Critical Elements

• f the
• f the

Engagement Process

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Element Element – – 1 1

 Clarify the helping Process for the client…

Clarify the helping Process for the client…

• Carefully introduce self, agency intake process, and possible service

Carefully introduce self, agency intake process, and possible service

• ptions.
• ptions.
• Do not assume that client has been given accurate information

Do not assume that client has been given accurate information about services. about services.

• Do not assume clients know what is expected of them and what

Do not assume clients know what is expected of them and what they should expect from intake process/worker they should expect from intake process/worker

Element Element – – 2 2

 Develop the foundation for a

Develop the foundation for a collaborative

collaborative

working relationship working relationship working relationship… working relationship…

• Balance the need to obtain intake information (agency

Balance the need to obtain intake information (agency assessment, insurance forms, etc.) with helping the child assessment, insurance forms, etc.) with helping the child and family to “tell their own story” about why they have and family to “tell their own story” about why they have come. come.

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Element Element – – 3 3

 Focus on immediate, practical concerns…

Focus on immediate, practical concerns…

• Be ready to schedule a second appointment sooner than the

Be ready to schedule a second appointment sooner than the following week. following week.

• Parents often need help negotiating with other “systems” (i.e.

Parents often need help negotiating with other “systems” (i.e. school). school).

• Responding to parents concerns provide an opportunity for worker

Responding to parents concerns provide an opportunity for worker to demonstrate their commitment and potential capacity for help. to demonstrate their commitment and potential capacity for help.

Element Element – – 4 4

 Identify and problem

Identify and problem-

• solve around barriers to help

solve around barriers to help seeking seeking

• Every first interview must explore potential barriers to obtaining

Every first interview must explore potential barriers to obtaining

• ngoing services
• ngoing services
• Specific obstacles, such as time and transportation must be

Specific obstacles, such as time and transportation must be addressed. addressed.

• Other types of barriers include previous negative experiences

Other types of barriers include previous negative experiences with helping professionals; discouragement by others to seek with helping professionals; discouragement by others to seek professional help; differences in race or ethnicity between the professional help; differences in race or ethnicity between the interviewer and the client; families experiences with racism and interviewer and the client; families experiences with racism and its impact on their willingness to receive services from a its impact on their willingness to receive services from a “system” need to be carefully explored “system” need to be carefully explored system need to be carefully explored. system need to be carefully explored.

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First Interview Study Methods First Interview Study Methods

 Outcome of interest: # of families that

Outcome of interest: # of families that t i iti l d i i t t t i iti l d i i t t came to initial and ongoing appointments came to initial and ongoing appointments

 Setting: Outpatient child mental health

Setting: Outpatient child mental health clinic clinic

 Sample:

Sample: n n= 107 = 107

 Design: Random assignment to condition

Design: Random assignment to condition

 Design: Random assignment to condition

Design: Random assignment to condition

First Interview Results First Interview Results

120 40 60 80 100 % for first interview (n=33) % for comparison (n=74) 20 Accepted 1st Appt. 2nd Appt. 3rd Appt.

19 Collaborating with families to enhance outpatient Collaborating with families to enhance outpatient mental health and school based services mental health and school based services

• Multiple family group approaches

Multiple family group approaches Multiple family groups Multiple family groups

• Target family factors that have been empirically

Target family factors that have been empirically linked to childhood conduct difficulties linked to childhood conduct difficulties linked to childhood conduct difficulties linked to childhood conduct difficulties

• Focus on practical parenting strategies that can

Focus on practical parenting strategies that can be immediately incorporated in order to reduce be immediately incorporated in order to reduce stress and increase optimism stress and increase optimism

• Build upon family strengths and reduce stigma

Build upon family strengths and reduce stigma Add b i t i i ti Add b i t i i ti

• Address barriers to service use via active

Address barriers to service use via active problem solving problem solving

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In the words of families… In the words of families… Multiple family groups should focus on: Multiple family groups should focus on:

• Rules

ules

• Roles and Responsibilities
• les and Responsibilities
• Respectful communication

espectful communication

• Relationships

elationships Multiple family group intervention outline Multiple family group intervention outline

Session 1 Session 1 What are multiple family groups? What are multiple family groups? S i 2 S i 2 B ildi f il t th B ildi f il t th Session 2 Session 2 Building on family strengths Building on family strengths Session 3 Session 3 Rules for home and school Rules for home and school Session 4 Session 4 Responsibility at home and at Responsibility at home and at school school Session 5 Session 5 Relationships Relationships Session 6 Session 6 Respectful communication Respectful communication Session 6 Session 6 Respectful communication Respectful communication Session 7 Session 7 Dealing with stress at home Dealing with stress at home Session 8 Session 8 Who can we turn to (building Who can we turn to (building supports)? supports)?

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Multiple family group intervention outline Multiple family group intervention outline

Session 9 Session 9 Fixing broken rules Fixing broken rules Session 10 Session 10 Everyone does their share in Everyone does their share in Session 10 Session 10 Everyone does their share in Everyone does their share in solving problems solving problems Session 11 Session 11 Building kids up Building kids up Session 12 Session 12 Everybody gets a chance to be Everybody gets a chance to be heard heard Session 13 Session 13 Dealing with stress/Finding Dealing with stress/Finding resources resources Session 14 Session 14 Stress & resources Stress & resources -

• Part II

Part II Session 15 Session 15 How did group go? How did group go? Session 16 Session 16 Ending party Ending party

MFG study methods MFG study methods

• Outcome of interest:

Outcome of interest: % of families in % of families in attendance & child mental health attendance & child mental health attendance & child mental health attendance & child mental health symptoms symptoms

• Setting:

Setting: urban outpatient child mental urban outpatient child mental health clinic health clinic

• Sample:

Sample: n= 88 = 88

• Design:

Design: consecutive referrals for conduct consecutive referrals for conduct difficulties were assigned first to MFG until difficulties were assigned first to MFG until spaces filled and then to services as usual spaces filled and then to services as usual

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Results: % Involvement in MFGs vs. Clinic Results: % Involvement in MFGs vs. Clinic Comparison Comparison

120 100 91 59 95 84 39 40 60 80 100 MFG (n=34) Comparison (n=54) 20 ever 3 sessions 16 sessions

Changes within child serving systems Changes within child serving systems

O i f O i f

 Overview of

Overview of engagement teams engagement teams

 Collection of data

Collection of data related to related to engagement engagement

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Quality Mental Health Services Quality Mental Health Services

 Consumer Centered

Consumer Centered

 Knowledge Based / Data Driven

Knowledge Based / Data Driven

 System Oriented

System Oriented

Definition of quality Definition of quality

 The degree to which health services for

The degree to which health services for i di id l d l ti i th i di id l d l ti i th individuals and populations increase the individuals and populations increase the likelihood of desired health outcomes and likelihood of desired health outcomes and are consistent with current professional are consistent with current professional knowledge. knowledge.

– IOM, 1990 IOM, 1990 ,

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Model of quality improvement Model of quality improvement

 Shifts away from retrospective methods to

Shifts away from retrospective methods to concurrent and/or prospective approaches concurrent and/or prospective approaches

 Continuous Quality Improvement

Continuous Quality Improvement

The continuous quality improvement cycle The continuous quality improvement cycle

Input Plan Act Do Check

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CQI cycle CQI cycle

 Plan

Plan – – define organizational plan for define organizational plan for lit ti d t t d lit ti d t t d quality tied to customer needs. quality tied to customer needs.

 Do

Do – – improve organizational performance improve organizational performance

• n key indicators.
• n key indicators.

 Check

Check – – assess how well the services assess how well the services delivered in “DO” phase accomplished the delivered in “DO” phase accomplished the delivered in DO phase accomplished the delivered in DO phase accomplished the

• bjectives in “PLAN” phase.
• bjectives in “PLAN” phase.

 Act

Act – – evaluate and refine quality plan. evaluate and refine quality plan.

Learning Collaborative Performance Learning Collaborative Performance Indicator # 1 Indicator # 1

(by month by month across 13 agencies) across 13 agencies)

100 59 72 78 80 75 78 10 20 30 40 50 60 70 80 90 % of kept intake appts. (Learning Collaborative Members) baseline 10 O c t . N

• v

. D e c . J a n . F e b . M a r

26 Estimates of number of children completing an Estimates of number of children completing an intake as a result of quality improvements related intake as a result of quality improvements related to engagement to engagement

350

baseline

216 264 286 293 275 286 50 100 150 200 250 300

baseline all (representing 324 more children that received an intake over the 5- month Learning

50 O c t . N

• v

. D e c . J a n . F e b . M a r .

month Learning Collaborative)

Summary & Wrap Summary & Wrap-

• up

up

 Final questions and answers

Final questions and answers