the CANS in SF:the CANS in SF:Process, Progress, PromiseProcess, Progress, Promise

April 19, 2010April 19, 2010

Nathaniel Israel, PhDNathaniel Israel, PhD

SFDPH CBHS CYF-SOCSFDPH CBHS CYF-SOC

Thank-Yous..Thank-Yous..

• San Francisco’s Children, Youth, and San Francisco’s Children, Youth, and FamiliesFamilies

• Sai-Ling Chan-Sew, Director CYF-SOCSai-Ling Chan-Sew, Director CYF-SOC

• Community Programs AdministrationCommunity Programs Administration

• John LyonsJohn Lyons

• Clinicians, Case Managers, and Clinicians, Case Managers, and Program DirectorsProgram Directors

Presentation: Pro, Con, Presentation: Pro, Con, ProcessProcess

• Morning: High EnergyMorning: High Energy

• First Talk: High ExpectationsFirst Talk: High Expectations

• Our Way Through: Our Way Through: – Values of CANSValues of CANS

•Collaboration: Audience ParticipationCollaboration: Audience Participation

•Outcome Focus: Objectives in BoldOutcome Focus: Objectives in Bold

Starting Point: Get Out!Starting Point: Get Out!

• 22 Programs22 Programs• 3 Advocacy Groups3 Advocacy Groups• 2 Themes:2 Themes:

– ProgramsPrograms•Complex Needs of Children, Youth, Complex Needs of Children, Youth,

Families, CommunitiesFamilies, Communities•Provider History with CommunityProvider History with Community•Provider Confidence in Effectiveness of Provider Confidence in Effectiveness of

PracticePractice

FamiliesFamilies

• People in Systems aren’t listening to usPeople in Systems aren’t listening to us– If they are, they’re not changing anythingIf they are, they’re not changing anything

• Aren’t investing in usAren’t investing in us– Humanistic theory: don’t achieve our Humanistic theory: don’t achieve our

potential because something is in the waypotential because something is in the way– Here it’s the systems that pay our Here it’s the systems that pay our

paychecks: it’s uspaychecks: it’s us– Resources are there but they’re not being Resources are there but they’re not being

used effectively to help usused effectively to help us

Empowering NarrativesEmpowering Narratives

• Stories likely not newStories likely not new

• Never been collected in a way that Never been collected in a way that would allow us to:would allow us to:– Be forced to honor them andBe forced to honor them and– Find concrete “next steps” to take to act Find concrete “next steps” to take to act

in new ways that would better help in new ways that would better help familiesfamilies

Framework for ChangeFramework for Change

• Value:Value:– Put families and children first ; serve them effectivelyPut families and children first ; serve them effectively

• Tool:Tool:– the __ __ __ __the __ __ __ __

• Process:Process:– Become “communication rich” in actions that matter Become “communication rich” in actions that matter

most for children, youth and families most for children, youth and families

Initial ImplementationInitial Implementation

• Can we move from fights and Can we move from fights and frustrations to rational system that puts frustrations to rational system that puts families first in policy and progress?families first in policy and progress?

• FCMH:FCMH:– Long wait times for assessmentLong wait times for assessment– Under-serving FC populationUnder-serving FC population– Concern that treatment not matched to Concern that treatment not matched to

needneed

FCMH Implementation FCMH Implementation

• Lessons learned:Lessons learned:• Meaningful goals can be accomplishedMeaningful goals can be accomplished

– Wait time reduced by 2/3rdsWait time reduced by 2/3rds– Confidence that treatment matched to needsConfidence that treatment matched to needs

• Cross-system communication can become Cross-system communication can become understandable and rational understandable and rational – Requires persistent focus on outcomeRequires persistent focus on outcome– Everyone involved has to have access to Everyone involved has to have access to

information about the outcome that mattersinformation about the outcome that matters– Progress facilitated by weekly review of progress, Progress facilitated by weekly review of progress,

and problem solving to make more progressand problem solving to make more progress

Systemwide ImplementationSystemwide Implementation

• If you can do something on a small If you can do something on a small scale, then you can do it on a large scale, then you can do it on a large scale, right?scale, right?

• What could the possible barriers be?What could the possible barriers be?

BarriersBarriers

• System changes:System changes:– Move to HERMove to HER

•Antiquated system did not support any entry of Antiquated system did not support any entry of CANSCANS

•Had to switch to interim online systemHad to switch to interim online system

– Funding cutsFunding cuts

• Scaling Issues:Scaling Issues:– Massive increase in scale with no attendant Massive increase in scale with no attendant

staffing increase (1 program to 61 programs)staffing increase (1 program to 61 programs)

Uneven Pace of Uneven Pace of ImplementationImplementation

• Early AdoptersEarly Adopters– Take it and run!Take it and run!

• Hesitant Prove-its Hesitant Prove-its – Wait-and-SeeWait-and-See

• Kick the CANSKick the CANS– …….and hope it dies..and hope it dies.

Parallel ProcessesParallel Processes

• Clear need for both Technical and Clear need for both Technical and Social Implementation / Learning Social Implementation / Learning ProcessProcess– Chose local web-based app design firm Chose local web-based app design firm

(AJWI)(AJWI)– Began communication process to identify Began communication process to identify

and answer implementation issues, and answer implementation issues, identify system issues, and learn form identify system issues, and learn form successessuccesses

Social ProcessSocial Process

Multi-Level Training and Communication:Multi-Level Training and Communication:• CertificationCertification• SuperUswer CertificationSuperUswer Certification

– Applying CANS to practice (Treatment Applying CANS to practice (Treatment Planning, Identification of Outcome patterns)Planning, Identification of Outcome patterns)

• SuperUser CallsSuperUser Calls– Manuals: SUPSM, Tx Planning, EBCManuals: SUPSM, Tx Planning, EBC– Policy Development (transfer, aging up)Policy Development (transfer, aging up)– Using CANS to be explicit about treatment Using CANS to be explicit about treatment

goals, learn from each othergoals, learn from each other

Technical ProcessTechnical Process

Instant, Multi-Level Feedback from CANS:Instant, Multi-Level Feedback from CANS:

• Instant Feedback for Treatment PlanningInstant Feedback for Treatment Planning

• Instant visual of client needs / strengthsInstant visual of client needs / strengths– Evidence based, client based Clinical Evidence based, client based Clinical

Formulation Formulation

• Cross-time comparison of client progressCross-time comparison of client progress

• Cross-clinician data for supervisionCross-clinician data for supervision

• Program-Level Clinical FormulationProgram-Level Clinical Formulation

GoalGoal

• Utilize processes people are already Utilize processes people are already familiar with to make sense of and familiar with to make sense of and act on these new sources of child, act on these new sources of child, youth and family informationyouth and family information

Client –Level Formulation / Client –Level Formulation / Progress Progress

Program-Level Clinical Program-Level Clinical FormulationFormulation

Program-Level Clin. Form. Program-Level Clin. Form. (2)(2)

Program Clinical Program Clinical FormulationFormulation

0%

20%

40%

60%

80%

100%

B/E AngerControl

B/EDepression

B/EOppositional

B/EAdjustmentto Trauma

B/E ImpulseHyper

Risk BehSocial

Behavior

IOF SchoolBehavior

IOF SchoolAchievement

IOF Family IOFRecreational

Initial Assessment, n=28 Reassessment, n=15

But the learning and acting But the learning and acting can’t stop there…can’t stop there…

System-Level ProfileSystem-Level Profile

System-Level System-Level ProfileProfile

Cross-Agency ProgressCross-Agency Progress

Population Trajectory: HSA

0

5

10

15

20

25

1 2 3Assessment Number (6-month intervals)

Aver

age

Num

ber o

f Act

iona

ble

Item

s Pe

r Clie

nt

Progress in SF: ProcessProgress in SF: Process

• Value:Value:– Put families and children first ; serve them effectivelyPut families and children first ; serve them effectively

• Tool:Tool:– the __ __ __ __the __ __ __ __

• Process:Process:– Become “communication rich” in actions that matter Become “communication rich” in actions that matter

most for children, youth and families most for children, youth and families

Progress In SF: PresentProgress In SF: Present

• Now we have identified what are the Now we have identified what are the most pressing needs of our children, most pressing needs of our children, youth, and familiesyouth, and families

• We have identified the environments in We have identified the environments in which we must collaborate for successwhich we must collaborate for success

• We have a way to identify who we We have a way to identify who we need to learn more from to promote need to learn more from to promote effective practices for our children effective practices for our children youth and familiesyouth and families

Progress in SF: Next StepsProgress in SF: Next Steps

• Full circle with families: CANS Full circle with families: CANS education for treatment empowermenteducation for treatment empowerment

• ‘‘Digging in’ to practices that are Digging in’ to practices that are promising for familiespromising for families

• Combining knowledge of EBTs and Combining knowledge of EBTs and effective local practices to provide the effective local practices to provide the care with the greatest chance of care with the greatest chance of success for families success for families

Thank you!Thank you!

• Contact info: Contact info: nathaniel.israel@sfdph.orgnathaniel.israel@sfdph.org

• Complete your attendance sheet and Complete your attendance sheet and Evaluation sheet for CEUs / CMEs!Evaluation sheet for CEUs / CMEs!