Reports/Open CommunicationThe Director of Quality and Compliance is a direct link to the Quality Council (EMT) – report progress, findings, etc.
The role of the QI Department will be to support the Champions and Quality Improvement Teams. Champions will complete a quarterly report/update on the progress of the QI measure to QI Director and Quality Council.
Quality Initiatives Champion (s) will be assigned to each quality initiative.
Quality Improvement Teams will be created for each quality initiative – consisting of staff with the expertise, skills and knowledge needed. The Quality and Compliance Director is a support to all Quality Improvement Teams for support and guidance of quality initiatives.
VisionA bridge to a brighter future through lifelong learning
Core Values•Learning as a focus across all Glade Run’s programs as evidenced by:
•Discerning the strengths and cultures of families•Emotional and behavioral management to facilitate academic achievement
•Innovative learning opportunities for staff, children and families•Program excellence and positive impacts as evidenced by:
•Partnerships with families to understand their needs and achieve success at home and in the community•Data that indicates successful outcomes for individuals and families
•Improved academic performance•High satisfaction ratings
•A welcoming culture•Working with individuals and families in the most appropriate setting available
•Work environments that thrive on the seven commitments of sanctuary•Our Christian foundation
MissionLinking Faith and Service
QUALITY COUNCIL (EMT)
Program Excellence Through Lifelong Learning
Life Long Learning: Staff,families/individuals and other professionals gainknowledge and competence through training and skillattainment
EPT: Implements the strategic goals established by the EMT while ensuring program excellence and compliance
EMT: Oversees program excellence and strategic growth
EST: Provides support for the EMT and EPT to achieve program excellence and strategic growth
EMG consists of EMT, EPT, and EST. The implementation and leadership of the Continuous Quality Improvement initiatives is the responsibility of the EMG.
Goals and Action Steps to Achieve Outcome/Impact
Quality Initiatives Impact Statement; The end result of the Quality Initiative
Quality Initiative Measurement Tools
Quarterly Summary/Follow-up
Family Partnership: Families feel empowered in the decision making process and express a sense of connectedness to supportive networks
Academic Excellence:The learning environmentat St. Stephen’s LutheranAcademy reflects academic excellence and an Accountable, Safe and Kind environment
Individualization/Generalization: families/individuals learn and practice skillsthat will transfer to theirunique home and communitysettings
Evidence Based Practices: Program excellence is achieved with the training and utilization of evidence based practices
1. Training records will identify the completion of career track trainings.
2. Quarterly training effectiveness survey’s
2. New hire surveys initial and at first quarter
4. Google analytics will be used to evaluate utilization of web-based trainings.
5. Clinical case review evaluations/checklists
5. Skill evaluation checklists
5. Exit interviews/ Review and revise to include skill development
Retention rates
Parent survey
PAS audits reviews
1. Develop career tracks for all job classifications
2. Assess, prioritize and evaluate training needs for staff, individuals families and other professionals
3. Educate and train employees and supervisors regarding career tracks.
4. Design web-based trainings
5. Develop professional skill evaluation checklistsEstablishment of learning goals for employees
Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools.
Lifelong LearningChampion Nickole Pribozie
Staff, families/individuals and other professionals gain knowledge and competence through training and skill attainment
Measurement Tool Responsible Person Frequency
Review training records for career track completion
Nickole Pribozie Quarterly (Oct, Jan, April, July)
Training effectiveness surveys
Nickole Pribozie Quarterly (Oct, Jan, April, July)
Training Needs survey Nickole Pribozie Semi-Annually
Clinical Case Review evaluations
Program Managers/supervisors
90 days and Annually
Retention Rates Tina Lynch Semi-Annually (Sept, March)
Quarterly summary/follow upLife Long Learning
• 105 Training Assessment needs have been completed. This is a six Question survey to identify training needs by position. This data is currently being evaluated to help assist in the continued development of Career Tracks.
• 70 Training Evaluation surveys have been completed. The surveys are administered after new hire training and then again at the quarterly basis. The survey is an eight question survey that evaluates the employees skill confidence to job duties and an evaluation of the effectiveness of the trainer to deliver the material in a way that the employee is able to relate the training to skill development and job preparedness.
• Average score of 4.27 on the Question I feel the training provided me new knowledge or insight.
• Average score of 4.67 on the question “I feel confident that I have the knowledge and skills to be able to use what I learned in my work”
• Average score of 4.59 on the question “Overall, this training will help me do my job well.”
• Five new trainings created by Glade Run have been added to Essential Learning (Residential 3800 regulations, Child Psychomarmacology, Sanctuary module 3 and 4, welcoming environment and HIPAA security.)
Quarterly summary/follow upLife Long Learning
Six career tracks have been developed
•Direct care – includes TSS, MHW’s, Teaching Assistants, Adventures staff•Therapist – MHP, BSC, Mobile therapists•Clinical Supervision•Leadership•Support Staff•Case Management
New Trainings developed
•Progress note training utilizing DAP format. (56 have attended)•BHRS Redesign•Sanctuary Modules•Alolescent and Autism•CAASP principles•Suicide Prevention
Orientation and Training Surveys
Training Survey’s
Q 1 Overall Score
Q2 Overall Score
I feel confident that I have the knowledge and skills to be able to use what I learned in my job
81 4.28% 76 4.38%
I feel the training provided me new knowledge and insight 81 4.63% 76 4.53%Overall, this training will help me do my job well 81 4.64% 76 4.47%
1st Q Agree Strongly Agree
2nd Q Agree Strongly Agree
Employee orientation has increased my excitement about working at Glade Run
4 25% 75% 8 12.5% 75%
I have a clear understanding of the history of Glade Run
4 25% 75% 8 37.50% 62.5%
I understand how the values of Glade Run impact the work that we do
4 25% 75% 8 12.5% 87.5%
I am familiar with the services provided by Glade Run
4 25% 75% 8 50% 50%
I have a basic understanding of the sanctuary model
4 25% 50% 8 37.5% 62.5%
I know where to learn more about any of the topics covered
4 50% 50% 8 37.5% 62.5%
I feel welcomed by Glade Run 4 100% 8 25% 75%
New Hire Campus Orientation Survey
Community New Hire Orientation survey
1st Q Agree Strongly Agree
2nd Q Agree Strongly Agree
Employee orientation has increased my excitement about working at Glade Run
3 33.33% 66.67% 2 100%
I have a clear understanding of the history of Glade Run
3 66.67% 33.33% 2 100%
I understand how the values of Glade Run impact the work that we do
3 33.33% 66.67% 2 100%
I am familiar with the services provided by Glade Run
3 66.67% 33.33% 2 50% 50%
I have a basic understanding of the sanctuary model
3 66.67% 33.33% 2 50% 50%
I know where to learn more about any of the topics covered
3 66.67% 33.33% 2 100%
I feel welcomed by Glade Run 3 50% 50% 2 100%
Family PartnershipChampion Leslie Walter
Grow the Glade Run Family network data base
Increase decision making and participation of families in agency events/activities
family partnership support will increase visibility and continue communicating their role in glade run culture
Family advisory counsel continues to grow and become involved in decision making and planning.
Families/Individuals feel empowered in the decision making process and express a sense of connectedness to supportive networks
Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools
Review the number and percentage of active participants in the Glade Run Family Network Database
Review family participation/voice in treatment plans, progress notes and ISPT and treatment plan signature pages
Training recordsReview advisory counsel minutes.
3, 6, 9 month aftercare calls
Family satisfaction surveys
Database communication form.
Measurement tool Person responsible Frequency
Advisory Counsel Minutes Leslie Walter Quarterly
Review Family Network database
Leslie Walter Quarterly
Family satisfaction Surveys TBD TBD
Review Treatment plans, progress notes, signature pages
Ruth Girton 10% records quarterly
3, 6, 9 month after care calls TBD Monthly, Quarterly summary
• To Date there are 147 families entered into the data base..– 97% would like to receive updates on family/community events– 76% would like to become more involved and share their voice and experience with us.– 78% would like information on how to connect with other families– 53% would like to be connected to spiritual and/or other supports within the community– 93% would like to receive the Glade Run newsletter, The Bridge.
• Parent satisfaction surveys are in final stages. The survey is complete just working out the process for administration, frequency and person responsible.
Quarterly summary/follow upFamily Partnership
Quarterly summary/follow upFamily Partnership/First Quarter
Family Partnership/2nd Quarter Update
• Advisory Counsel meeting quarterly and have added 5 new members.• Continue to bring sanctuary to meetings and to our families• Working on how to bring the families together. Several families did help on the family survey• Working with Training Department to develop and deliver the training. • Finalized Family Satisfaction Survey’s. Sent out approximately 2000, and have received back more than 10%,
good representation among all program areas. • Working with families to find out what trainings they would like to have. Identified behavior management and
parenting skills as first focus based on survey feedback. • Changed the way we do medication sheets for therapeutic leaves based on feedback from a family member
through the survey.• Utilization of e-blast to share stores, events, themes, resources etc.
• Still working on how to show family engagement with the agency. There has been a recent culture change to include families in events such as Marthen’s and Reiber’s cottage families events, positive parenting in Beaver Falls and the Jeremiah Village community information sharing meetings.
Quarterly summary/follow upFamily Partnership
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 1 8 34 56 4.46 99990
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
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0 4 6 36 53 4.39 99990
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Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 3 10 42 44 4.28 99990
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Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 0 5 31 62 4.58 98981
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Family Satisfaction Survey
Answer Options
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2. I am asked for my input about the strengths and needs of my family.
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3. I helped to create the current goals.
4. Glade Run staff are friendly and polite.
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1. I feel Glade Run staff are welcoming.
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Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 8 12 29 49 4.21 98981
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
2 4 17 37 38 4.07 98981
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Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 1 14 33 50 4.35 98981
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Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 1 5 37 55 4.49 98981
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7. Glade Run staff show concern for my family's improvement.
5. I receive updates on progress towards goals.
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Answer Options
8. I have a voice regarding decisions involving care, treatment and services.
6. I receive information about the services available at Glade Run.
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Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 2 16 43 37 4.17 98981
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 6 22 35 35 4.01 98981
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
1 10 27 27 33 3.83 98981
Answer Options
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9. My needs are being addressed.
answered question
11. Glade Run staff are helping/have helped me build a supportive network in my community (family, friends, resources, etc.).
answered question
10. I receive information on resources/events that are relevant and beneficial to me.
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Family Satisfaction Survey - Sanctuary
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 2 7 38 52 4.41 99990
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 1 8 34 56 4.46 99990
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
1 0 6 33 59 4.51 99990
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 1 2 27 69 4.66 99990
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 0 5 31 62 4.58 98981skipped question
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Family Satisfaction Survey
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3. I can openly communicate without feeling judged.
4. I am treated with respect.
1. My rights and responsibilities were explained to me and I know how to find this information, when needed.
5. Glade Run staff are friendly and polite.
Answer Options
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2. I feel Glade Run staff are welcoming.
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Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
1 8 9 24 56 4.29 98981
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 8 12 29 49 4.21 98981
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 1 14 33 50 4.35 98981
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 1 5 37 55 4.49 98981
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 2 20 26 50 4.27 98981skipped question
10. The program is helping my family.
answered question
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8. Glade Run staff show concern for my family's improvement.
7. I receive updates on progress towards goals.
9. I have a voice regarding decisions involving care, treatment and services.
Answer Options
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6. Glade Run staff routinely communicate with me.
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 0 19 29 50 4.32 98981
Strongly Disagree
Disagree Neutral AgreeStrongly Agree
Rating Average
Response Count
0 2 16 43 37 4.17 98981
11. Glade Run staff promote safety for all.
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12. My needs are being addressed.
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Academic AchievementChampion Amy Williams
The learning environment at St. Stephens’ Lutheran Academy reflects academic excellence and an Accountable, Safe and Kind environment
85% attendance Rate
Grades will improve school wide
Major incidents will decrease (Acts of violence, self injurious behavior, awol, restraint, police involvement, psychiatric hospitalization)
Students will demonstrate increased proficiency in reading comprehension and math
Implement the CBITS
Classroom Engagement
Attendance Records
School wide grade reports
Positive Behavior Support Assessment; Incident Report review; ASK points
Aims-WEB reports
CBITS evaluation tools
Walk through observation/evaluation cards
Goal Attainment Scale Leadership groups
Teacher and teacher Aid staff retention
Staff, student, parent, school district surveys
Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools
Education
Measurement Tool Person Responsible Frequency
Attendance Records Jayme Glover 9 week intervals and end of school year
School wide grades Jayme Glover 9 week interval and end of school year
PBIS Keenon McGaughey Semi-annually
Walk thru engagement cards
Amy Williams, Keenon,McGaughey Ruth Girton, Beth Hines
10 per month
Student, family surveys TBD TBD
ASK points Jayme Glover Semi-annually
Incident report review Jayme Glover Quarterly
Quarterly summary/follow up
•Education observation/evaluation cards
Observed to a high degree
Observed to be effective and appropriate
Observed Needs further development
Not observed Needs improvement
StudentEngagement
11/46 24% 19/46 41% 16/46 35% 0
Staff Engagement
5/46 11% 23/46 50% 16/46 35% 0
Classroom engagement
9/46 20% 12/46 26% 12/46 26% 0
APoss.
A% A S
Poss.S
% S KPoss.
K% K
Total ASK Points
Total ASK Points
Possible
Percentage ASK Point Earned
35658 38591 90.73% 37457 38597 96.84% 36517 38610 95.08% 109632 115798 94.31%
6362 7010 90.12% 6733 7011 96.03% 6554 7012 97.79% 19649 21033 94.19%
11419 12176 93.30% 11991 12189 100.00% 11769 12189 99.24% 35179 36554 95.25%
17877 19405 92.12% 18733 19397 96.57% 18194 19409 93.74% 54804 58211 94.49%
Individualization/GeneralizationChampion Beth Hines
Families/individuals learn and practice skills that will transfer to their unique home and community settings.
Strength Needs and Cultural Discovery Treatment Plan Reviews
Goal Attainment Scale
Parent/client surveys
3, 6 and 9 month after care surveys
Treatment plan reviews
Progress Notes review
100% of Treatment plans will identify family strengths and prioritized needs
100% of Treatment plans will develop goals and interventions to include natural and informal supports
Progress note format training
Progress notes reflect evidence of skill transfer through teaching, modeling, evaluation and/or monitoring
Goals and Action steps to Achieve Outcome/Impact Quality Initiative Mesurement Tools
Quarterly summary/follow upIndividualization/Generalizaion
– 1, 3, 6, 9 month after care calls were centralized and created using survey monkey.• There have been 111 aftercare calls attempted for the RTF and 553 for the community
programs• surveys were successfully completed for the community programs
30 Day Surveys: (84 Surveys Community)• 88% of clients were still living in the home they discharged to • 75% in school or vocational training• 95% had not experienced a significant crisis requiring hospitalization• 85% reported the program being helpful• 76% using skills they learned in the program.
– 6 month Surveys (64 surveys Community)– 89% still living in the home they discharged to – 83% in school or vocational training– 89% had not experienced a significant crisis requiring hospitalization– 76% reported using skills they learned in the program– 79% reported program being helpful
RTF had a total of 51 total surveys answered
RTF (30 Day survey, 11 responses86% still in less restrictive placement62% made it to first aftercare appointment71% following aftercare plan35% felt they were doing better since discharge29% doing the same36% doing worse
RTF (60 Day survey, 12 responses)79% still in less restrictive placement80% following aftercare plan33% doing better33% doing the same33% doing worse
RTF (90 Day survey 1776% in less restrictive placement71% following aftercare plan41% doing better17% doing the same41% doing worse
RTF (180 day Survey 12 completed92% in less Restrictive75% still following aftercare plan33% reported doing better than at discharge16% doing the same50% doing worse
Response Count
76760
Response Percent
Response Count
100.0% 76760
Response Percent
Response Count
14.5% 1185.5% 65
760
Response Percent
Response Count
58.1% 250.0% 037.2% 164.7% 2
4333
6 Months
2. Date
No Contact Information (consumer's phone number is
30 Days
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Client Re-Admitted to Program/Treatment
Answer Options
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No Response (consumer did not return call or answer
1. Consumer's Name
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3. Type of Interview
Date of call:
answered question
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Community Post Discharge Survey
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Answer Options
Consumer Refused to Answer Questions
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4. If survey cannot be completed, indicate why.
Response Percent
Response Count
13.2% 1022.4% 1719.7% 156.6% 56.6% 52.6% 217.1% 132.6% 29.2% 7
760
Response Percent
Response Count
88.0% 2212.0% 3
2551
Response Percent
Response Count
8.3% 291.7% 22
2452
Response Percent
Response Count
4.0% 196.0% 24
2551
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BHRS- Beaver
7. Have you been arrested since discharge?
No
Answer Options
Family Based - Butler
answered question
BCM - ButlerBCM - Beaver
Yes
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8. Have you experienced a crisis that resulted in a psychiatric hopsitalization?
Family Based - Beaver
No
Answer Options
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BHRS - Pittsburgh
Yes
Answer Options
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6. Are you currently living in the same home as when you were discharged?
No
Family Focused Solution Based
BHRS - Butler
Answer Options
5. Program:
Yes
Family Preservation-Reunification
Response Percent
Response Count
0.0% 0100.0% 25
2551
Response Percent
Response Count
60.0% 1516.0% 424.0% 6
2551
Response Percent
Response Count
0.0% 0100.0% 25
2551
Response Percent
Response Count
8.0% 220.0% 572.0% 18
2551
Response Percent
Response Count
88.0% 2212.0% 3
2551
answered question
10. Are you currently taking your prescribed medication?
Yes
No
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11. Are you currently involved with or receiving services from CYF (Children, Youth, and Families)?
Yes
N/A (No medications prescribed)
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Yes
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No
12. Are you currently employed?
Answer Options
No
13. Are you currently attending school, college, or a vocational program?
Yes
N/A (Consumer is a child)
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9. Have you been voluntarily hospitalized?
Yes
answered question
No
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Answer Options
No
Evidence Based PracticesChampion Beth Hines
Program excellence is achieved with the training and utilization of evidence based practices
Goals and Action steps to Achieve Outcome/Impact Measurement Tools
Research and obtain information on the following Evidence Based Practices (CBITS, DBT, CBT, TF-CBITS, PCIT, ABA, ART, SFT, PBIS) Academic curriculum,
Identify and develop who will become trained trainers in the above mentioned modalities
Train employees in the above mentioned modalities
Develop clinical coaching supervision model to ensure fidelity of the modalities
Measurement tools associated with each modality if indicated/available: Child PTSD scale (CPSS); Pediatric Symptom Checklist (PSC) CAFAS reports
Training records
Review supervision records
Quarterly summary/follow up
Evidence Based PracticesChampion Beth Hines
Program excellence is achieved with the training and utilization of evidence based practices
Goals and Action steps to Achieve Outcome/Impact Measurement Tools
Quarterly Summary/Follow up
Research and obtain information on the following Evidenced Based Practices:
•Cognitive Behavioral Therapy (CBT)
•Dialectical Behavior Therapy (DBT)
•Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
•Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
•Parent-Child Interaction Therapy (PCIT)
•Safe and Civil Schools Positive Behavioral Interventions and Supports Model (PBIS)
Identify and develop who will become trained trainers in the above mentioned modalities
Train employees in the above mentioned modalities
Develop clinical coaching supervision model to ensure fidelity to the modalities
Measurement tools associated with each modality if indicated/available:
Suicide Attempt Self Injury Interview (SASII); Nonsuicidal self-injury (NSSI)
Child Behavior checklists; child depression inventory; Weekly Behavior report; Parent Emotional Reaction Questionnaire ; Parenting Practices Questionaire (PPQ); Parent Support Questionnaire (PSQ)
Child PTSD symptom Scale (CPSS); Pediatric Symptom Checklist (PSC);
Dyadic Parent-Child Interaction Coding System (DPIS); Parenting Scale (PS); Eyberg Child Behavior Inventory (ECBI); Child Behavior Checklist;
Home Situations Questionnaire—Modified (HSQM); Parenting Stress Index (PSI); Parent Locus of Control Scale (PLOC); Parent Sense of Competence Scale (PSOC);
An Academic Index Kentucky Core Content Tests; California Standards Test in Mathematics; Positive Behavior Support (PBS) Assessment—Staff survey; Teacher Surveys
Training Records
Review Supervision records
3, 6, 9 month aftercare calls
Treatment retention
Quarterly summary/follow up
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