Sustainability and EBP’s:The Right Ingredients

2014 Fourth Annual DC Summit

Helen M. Midouhas, M.S. Ed., L.P.C.FFT LLC

Such as:◦ Core elements needed for long-term sustainability

◦ Implementation elements that are constants (firm) and elements that are flexible to unique agency characteristics

◦ Surprising (and not surprising) findings

What are the Elements of successful Implementation?

Share results of study of FFT sites that have sustained (Based on Findings of FFT sustainability study with 7-15+ year

old FFT sites (Kopp, D., & Hollimon, A.)

1. Participants will be able to list at least 3 “ingredients” needed for a sustainable EBP

2. Participants will be able to describe the relationship between fidelity and outcomes

3. Participants will be able to discuss ways to enhance current programming in at least one of the following domains: data collection, staff retention, referral process, monitoring

Learning Objectives

Functional Family TherapyBut First……

• Integrated / Research Proven Model• Behavior problem or at risk youth/families• Age range: 11-18• Short term intervention• Average of 12-14 sessions • Average between 3-6 months• Service Delivery Contexts• Juvenile Justice• Mental Health• Child Welfare / Social Services

Functional Family TherapyGlobal Dissemination Footprint

• 330 sites in 14 countries and most US states• 50,000 families served per year• 2,500 Therapists• Dissemination sites that are now 15 years out in the

implementation

Multiple Settings• Rural: Kansas, Iowa, Missouri, Wisconsin, Eastern WA, etc

Urban: NYC, Los Angeles, Kansas City, Denver, Minneapolis, etc.

Juvenile Justice• Child Welfare• Mental Health• School

• Statewide/Nationwide Projects• Washington, Pennsylvania, DC, Florida, Norway, • Netherlandsds, California, Maryland

Super Summary of the FFT Model and “FFT Attitude:” - A Philosophy / Belief System about people which includes a

core attitude of Respectfulness; of individual difference, culture, ethnicity, family form

- A family focused intervention involving alliance and involvement with all family members (Balanced alliance) with therapists who do not “take sides and who avoid being judgmental.

- A change model that is focused on risk and (especially) protective factors – “Strength Based””

- With interventions that are specific & individualized for the unique challenges, diverse qualities, and strengths (cultural, personal, experiential, family forms) of all families and family members.

- And an overriding Relational (versus individual problem) focus

Principles of FFT

Core Elements

Respect-based

Integrated/ Multisystemic

Data Driven

Phase-Based

Copyright FFT LLC 2012

FFT Phases

GENERALIZATION

BEHAVIOR CHANGE

SESSIONS

PRE

TREATMENT

POST

TREATMENT

MOTIVATION

Relational Assessment

ENGAGMENT MOTIVATION

Functional Family Therapy-Research (1971-2014)

Outcome Studies◦ 25-60% reductions in recidivism ◦ RTCs and Effectiveness studies

◦ Sustainable effects, demonstrated repeatedly• From 1 – 5 years after intervention • 3 Yr follow up prevention effects for siblings• Positive effects on parent/adult mental health Improved retention/lower dropout

◦ Child Welfare—39% reduction in out of home placement and decreased units of service by half

◦ Family functioning improvement

◦ Cost Benefits (as of 2013) $18.98 saved for every $1 invested $61,370 benefits vs. $3,261 costs per case

DC FFT Projects

Hillcrest Children & Family Center

First Home Care

• Implemented in Fall 2010, as of 2014, 25+ therapists providing FFT in D.C.

• FY 12-13 FFT had an 70% successful closure rate with over 250 youth and families served

• 90% or higher rate for ultimate outcomes

PASS

Gathered data from 46 teams that have been successfully implementing FFT 7+ years

Respondents were team leads or administrators

Question domains:◦ Team (therapists, supervisors)◦ Referrals◦ Funding◦ Agency/Organization (culture, incentives, support)◦ Data utility

FFT Sustainability Study

Last three years site 1.7% of sites closed.◦ Extremely low referrals

Little relationship with referral source◦ State level changes/re-bidding or program changes

During last five years lost 3.8% of sites

96% retention

FFT site attrition rates are refreshingly low

While we might have in some cases accidentally done things that lead to FFT being sustained in a community, sustainability is not an accident.

How we begin has everything to do with where we end up

While we heavily emphasize information on outcomes with families, data on youth/family change is even more important to sustainability than we thought.

Regardless…Implementation (or “putting into effect”) has an ongoing nature.◦ No program in practical terms reaches stasis (some equilibrium that

doesn’t require attention). Service systems, therapists, teams, organizations are too dynamic.

Themes…

FFT Sustainability Study (7+ year sites)

Yes No0%

20%

40%

60%

80%

100%

Does data support the suc-cessful continuation of FFT in

your community?

Replicate therapist practice in evaluations and thus replicate the outcomes of those evaluations at community sites. Or adherence.◦ “Train, evaluate, close project” VERSUS lasting practice change

that achieves consistent outcomes.

FFT LLC creates apparatus to support ongoing fidelity… Training and consultation protocol Monitoring, assessing, and correcting practice via assessment and

web based protocol Creating internal infrastructure to do this

1999…Fidelity and outcomes

6 month 12 months 18 months0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Adherent Non-Adherent

Washington Statewide Probation Implementation

Adherence and Clinical Outcomes

* Statistically significant outcome as compared to the control condition

Washington State Institute for Public Policy, 2002N=980

38% reduction in felony crime

50% reduction in violent crime

$18.98 return for each $1 invested

$2100 perfamily cost to implement

Learning from WA state: fidelity = outcomesA lot of pressure so that by 2007 such an emphasis on the methods to understand/assess practice became an overemphasis

Losing the central fact that fidelity IS actual practice◦ Example: a good behavior change progress note is different (though

perhaps linked) to doing an excellent behavior change session/s.

Separate clinical adherence from dissemination adherence. Dissemination adherence may help us understand clinical fidelity but it’s not the same thing.

Fidelity part two

SUSTAINABILITY

The context in which therapists operate and are supported doesn’t just impact but ALLOWS fidelity (outcomes) and sustainability

1999-2003◦ focus on creating a welcoming “noise-free” environment for FFT

practice

Increasing focus on state/nationwide support and data systems for FFT (i.e. CA, FL, PA, MD, Wash DC, WA, Maine, Norway, NL)

Increased focus on providing aggregate data and focused QI data

Community Development Team process in CA retain 45 out of 50 sites over 11 years

Increased experimentation with complimentary case management systems (FFP) to create a more supportive context

Diversify funding (medicaid) A word about Medicaid: it can help, or erode, or take us off model…it

depends which state you operate in

Larger scale sustainability efforts

Simply understand dissemination better ◦ Highly skilled consultants and trainers

Avg of 9.6 years experience in doing FFT, supervising, consulting with other sites, and training

Work at and are selected from the 1000+ Staff dedicated to funding issues, particularly Medicaid Always clinically grounded by Jim Alexander and Mike Robbins

◦ Increasingly organized statewide systems Stronger and more responsive use of data

◦ With therapists, teams, multiple teams, states and nations◦ All without losing clinical responsiveness◦ Addition of Behavior change modules fitted to FFT

As a training organization…

◦ Critical throughout but particularly in first year◦ Referral systems/agent that understand FFT and

operate in ways that support the FFT practice Working with families Completion based on FFT model Not saturating families with too many referrals

alongside FFT (or ones that work against FFT). Appropriate and ample #s referrals

◦ More familiesmore opportunities to apply FFTmore opportunities for successbuilds confidence and motivates

A word about referrals

Regardless of type of agency, location and families served, these elements are crucial:◦ Administrative support of EBP, FFT, the team◦ Positive relationship with community partners

Champions in the agency and community Routine meetings and open communication

◦ Sufficient referrals for full utilization◦ Referrals that are appropriate◦ Hiring practices and job expectations specifically

tailored to implementing FFT◦ Embracing and utilizing QA practices & feedback

Core Elements for Sustainability

Almost 90% MA level or higher 92% have caseloads between 10-15 Almost 80% of supervisors carry caseloads

of 3 to 10, with 26% carrying btw 7 and 10 78% have team sizes between 3 and 5

therapists Equal number of full and part time

therapists, but only one team with just part time therapists

Therapist/team key findings

Top therapist characteristics to create a lasting program◦ Confidence (85%)◦ Flexibility with schedule (77%)◦ Experience with home-based services (36%)◦ New to the field (25%)◦ High experienced therapists (18%)◦ Experience with EBTs (12%)

84% have specific job hiring practices and 75% have specific FFT job descriptions

Therapist/team key findings (2)

Single or multiple funding sources?

Do you have a single funding source or mul-tiple funding

sources?

Single Multiple0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Funding sources

Fund

ing

sour

ces yo

u us

e

Med

icai

d

Refer

ral S

ourc

e

Grant

fund

ing

Privat

e in

sura

nce

0

0.1

0.2

0.3

0.4

0.5

0.6

While less than 20% provide specific incentives for strong FFT performance, over 80% engage in FFT team building activities

Over 90% of agencies express a strong commitment to EBPs

78% provide other EBPs—they are not just FFT but believers in EBPs

Organizational key findings

Does your agency implement other EBPs as well as FFT?

Does you agency implement other

EBPs?

Yes No0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Other EBPs

What other

EBTs at agency?

MST TFCBT PCIT ART CBT DBT0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

Trainings Retreats Outings ·       B’day and team anniversary lunches Team dinners Awards breakfasts ·              Common team offices Flexible schedules Wellness activities Allowing for conference attendance and sharing with

team members Statewide trainings      

How sites to facilitate positive team culture

Respondents most significant challenges

incongruent funding

20%

therapist salaries low

20%

changes in funding12%

referral12%

finding right ther-apist8%

low agency support8%

low funding8%

training costs4%

multiple data entry4%

staff turnover4%

What makes FFT successful

commitment7%

high quality supervisor

14%

quality of team/therapists

16%agency support

27%

referral/com-munity support

18%

data/outcomes

18%

Multiple funding sources Smaller teams (3-5 members) Combination of primarily FTE and some PTE Not providing financial incentives But providing ample methods to promote

positive team culture◦ Flexible schedules, team outings/retreats,

celebration meals, recognitions by email and in meetings, focus on personal wellness, allowing for ongoing training for licensure

Characteristics tend to be…

Teams comprised of all PTE Large teams (6-8 therapists) Single funding sources BA level team members Small caseloads (5-7 families) Single referral types

Characteristics tend NOT to be:

Being purposeful in determining how the flexible elements can be tailored to unique implementation needs of each agency may be key to long-term success

Flexibility allows teams to weather the storms of funding changes, referral changes, agency changes

Lesson learned…

First Home Care, Hillcrest, PASS

Brendalan Jackson, FFT Site Supervisor Taleisha Ellerbe, FFT Site Supervisor Stephanie Sanders, FFT Clinical Supervisor

All three sites compare favorably with national study results, each will highlight a area of the study and how it is working for them.

Local Level Comparison

Agency overview

Program overview -Years in FFT and Phase of Team -Make up of team (FT, PT, caseloads) -Target population -Structure of your program -Your role in the program -Insights, thoughts, experience as a EBP

Hillcrest

What makes FFT successful

commitment7%

high quality supervisor

14%

quality of team/therapists

16%

agency support27%

referral/com-munity support

18%

data/outcomes18%

Quality of team and Agency support

What has Made Hillcrest FFT Successful

Agency overview

Program overview -Years in FFT and Phase of Team -Make up of team (FT, PT, caseloads) -Target population -Structure of your program -Your role in the program -Insights, thoughts, experience as a EBP

First Home Care

What makes FFT successful

commitment7%

high quality supervisor

14%

quality of team/therapists

16%agency support

27%

referral/com-munity support

18%

data/outcomes

18%

What Has Made FHC FFT Successful

No New Law Violations Remain in Home/Community In School, GED, Working

94%

95%

98%

FHC Ultimate Outcomes of Successful Closures

FHC Ultimate Outcomes of Successful Closures

Agency overview

Program overview -Years in FFT and Phase of Team -Make up of team (FT, PT, caseloads) -Target population -Structure of your program -Your role in the program -Insights, thoughts, experience as a EBP

PASS

What makes FFT successful

commitment7%

high quality supervisor

14%

quality of team/therapists

16%agency support

27%

referral/community

support18%

data/outcomes18%

Referral and community support

What has Made PASS FFT Successful

Along with constants…◦ Ample referrals◦ Well-trained, positive and strong FFT supervisor◦ Positive team culture◦ Funding◦ Agency support

There are elements that are necessary but can be integrated to unique agency with flexibility◦ Team: employees that are all FTE or FTE & PTE◦ Team size: larger or smaller ◦ Funding sources: multiple or single◦ Support: financial incentives or team culture

Constants & Flexibles

Questions & Comments

www.fftllc.com

Helen M. Midouhas, M.S. Ed., L.P.C.helen@fftllc.com

Stephanie Sanders, M.A., L.P.C.Stephanie.Sanders@uhsinc.com

Brendalan Jackson,

Contact