Improving Child Outcomes Through CARE, A Program Model by Cornell University. Council on Accreditation Innovative Practice. William Martin, MHSA

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1 Improving Child Outcomes Through CARE, A Program Model by Cornell University Council on Accreditation Innovative Practice William Martin, MHSA Assistant Executive Director Waterford Country School

2 Abstract Waterford Country School has been running high-quality congregate care programs for many years. For the last several years, the program leadership has sought ways to improve on child outcomes beyond the consistently positive levels, and tried many new initiatives without the desired success. Two years ago, the program had the opportunity to review the new CARE (Children and Residential Experiences) treatment model by Martha Holden from the Cornell University Family Life Development Center. The connection between the CARE model and what Waterford Country School was looking for was immediate. CARE provided a framework to tie together all the initiatives we thought were good for children and framed everything in the best interests of children. It also connected well with the Therapeutic Crisis Intervention model, also from Cornell that we adopted in The article details our journey into CARE and how it has changed our approach to the children in our care. It covers the two year period from the first trainings we received from Cornell, through our extensive training process and through the first year of implementation. More importantly, it covers the transformation of long standing quality practitioners as we abandoned much of what we knew and were comfortable in working with, in exchange for new approaches supported by research. Finally, we provide some early indicators of the effects of CARE on our children through three measures. All three areas show positive direction and promise that CARE is the vehicle to move our programs from good to great.

3 Improving Child Outcomes Through CARE, A Program Model by Cornell University The Agency Before CARE Waterford Country School (contrary to the name) is a comprehensive human service agency offering a continuum of services to special needs children and their families including residential treatment, group homes, emergency shelters, education, therapeutic foster care and in-home services. The Agency has been in business for almost 90 years evolving from a small, familyrun, home-based school for gifted and special needs children in New York to a large, elevenprogram non-profit agency of almost 300 staff, situated on a 350 acre main campus and four satellite sites. Achieving COA accreditation in 1992, the Agency has a long history of delivering quality services according to the highest standards. In an effort to continue to improve services and outcomes, the Agency followed and embraced many of the new directions of the times including several evidence-based models, strength-based treatment, trauma effects on treatment, performance-based accountability, Cornell s Therapeutic Crisis Intervention program (restraint prevention planning) and leadership models to enhance staff performance. Of the nine program administrators currently with the Agency, their average tenure is 19.2 years. This has enabled us to build upon our knowledge over a sustained period of time and put great effort into progressive thinking and study groups. We found that we struggled to organize and integrate new knowledge in a way that was complimentary to what we already knew and practiced. We were also open to more sweeping

4 change, but no one direction came through as a vehicle to go from a good solid Agency to a great one. CARE and Its Evolution In 2006, several agencies in South Carolina pooled their resources to commission the development of a best-practice model of treatment for children in congregate care. They approached the Cornell University Family Life Development Center who developed the Therapeutic Crisis Intervention model which is designed for children in congregate care and foster care and is practiced world-wide. Cornell University accepted the challenge and, under the direction of Martha Holden, Project Director for the Residential Child Care Project, began the research. First she gathered hundreds of direct care workers to determine their perception of practice competencies. Then an in-depth review of writings and research revealed that there was much more to know about how children change than had been put into practice. The CARE philosophy is that children are wired to do well and, when they don t, it is the responsibility of the staff to find out why and change accordingly. The agencies serving these children must develop a culture and climate that operates in the best interest of children and strives tirelessly to make them successful. The CARE model is founded on six principles and beliefs: developmentally focused, family involved, relationship based, competence centered, trauma informed, and ecologically oriented. It was in these principles that we found our answer. CARE provided WCS with a structure where many of our current initiatives fit and were connected through the notion of helping each child change while working in the best interests of the child.

5 The Introduction of CARE to WCS In the fall of 2008, WCS was involved in a consultation with Cornell University to reduce the use of restraints. When it was determined that the fundamentals of our crisis intervention system were sound, it was thought that the best way to achieve global restraint reduction was to focus on a change in the culture of the interactions between the staff and the clients and they offered us the CARE model to help us do so. In January of 2009, Martha Holden, Tom Endres and Jack Holden from Cornell University trained 25 of our staff for five full days in the CARE model. The training was difficult as it challenged many of our fundamental beliefs of how to help children in group care. The discussions in the training were deep and spirited and we slowly began to think differently. The curriculum calls for fewer rules and more expectations so we debated the notion of order vs. control. The material talks about the defeating nature of some behavioral incentive programs; so, we hotly debated what a treatment environment would be like without one. The research showed the suppressive effect of the blanket use of consequences to address pain-based behaviors, leading to hours discussing the pros and cons of alternatives. Our introduction to CARE was not a typical training program, but rather it was a challenge to all that we thought was right in group care. We were being challenged to trust the research and to take the risks of changing years of practice and thinking. Applying the principles of CARE were not at all instinctual. In fact, many of the skills were counterintuitive and we were being challenged to respond to behaviors with what the research said works, rather than to react to behavior with what our impulses guided us to do. At the end of the five days, many in our group were totally committed to the CARE model and the necessary changes that would ensue. That

6 sentiment, however, was not universal. Several of the participants were skeptical and less ready to give up some of their historical practices, and a few (very few) were not on board at all. Intensive discussions continued as we tried to process the new concepts and prepare to make the many changes that would lay ahead. The next step involved training trainers. From the original 25 staff who went through the CARE training, 19 volunteered to become trainers. Martha, Tom, and Jack returned to WCS for another three days to give us the skills and tools to train our staff. In the course of these three days, the CARE model became clearer, the concepts connected together and the fears of change began to evolve towards the excitement of implementing this model. We learned that the more familiar we became with the material, the better sense it made, and the more we were able to apply it in our interactions with our children. Then came the major challenge of training the 300 member staff of Waterford Country School. The first thing we did was determine that all employees in all programs would be trained. All program staff (with the exception of third shift) would receive the full five day training. Third shift staff and support services staff (food service, maintenance, office staff, etc.) would have the option to take an abbreviated version lasting about 2½ days. The decision to train support staff turned out to be a great one. Not only were they appreciative to be part of the program, but they began to see the importance to their contribution of the overall efforts with the children. The training was also a very personal experience for many of them as they connected the concepts with children in their own lives, not having as close a relationship with Agency children.

7 To train all of the staff, we divided the 19 approved trainers into three training teams and each team delivered a number of five-day and three-day trainings until all staff were trained. These trainings began in the summer of 2009 and were completed in January of Remarkably, as the trainings went on, the resistance to the new concepts decreased. Evaluations of the trainings by the participants consistently scored 4.5 out of 5 in terms of overall benefit/satisfaction. WCS Initiates Becoming a CARE Agency In the fall of 2009, at our Annual Administrative Planning Retreat, we officially launched the CARE program. Now with most of the staff trained, we could look at the change in staff practices which would constitute the next step in the implementation process. We started with an assessment of administrative buy-in. We felt that without a 100% commitment from the Administrative Team that we could not move forward. We reviewed the importance of congruence in the implementation and how our success would be based upon a constant striving for congruence. This is based in the notion that planned change to Agency culture and climate is a top down process. Twenty-six out of 26 administrators committed to the process and developed administrative objectives for the Agency based upon the six principles. They then developed a contract to enhance their own personal (but job-related) practices in terms of the principles. With this completed, we were ready for the formal adoption of CARE as our treatment model. The following day, all Agency supervisors and clinicians were invited to the retreat. We reviewed the principles and then divided up by programs to develop our CARE Implementation Plans. While some changes happened as a result of the training alone, we were now plan-fully in the change process. A fundamental premise of the CARE program is that children will do well if

8 they can, and if they can t, the job of the organization and every staff member is to provide an environment in which children can succeed. We began to shift the responsibility for the success of the children to the staff. We began to replace rules with expectations, the former being things that are easily broken, and the latter being things we strive to achieve. We started to ask ourselves when children were struggling, what happened to you and what do you need to be successful rather than what s wrong with you. We began to see that our behavioral incentive programs got in the way of our talking to the children about specific things they needed to concentrate on, and often hurt the child-staff relationships. We began to see the importance of relationships as a vehicle to helping children change. We began to see that treating all children the same was actually unfair and that each child had their own set of strengths and needs. We began to see that we overused consequences to address behaviors and that encouragement, teaching new skills and modifying expectations were more effective with many of the children. Basically, we began to change in many ways. Findings after One Year of Implementation It is now one year since our official implementation date. Subjectively, we feel we have developed a kinder, more supportive environment where the success of the children is our primary agenda. Children who are struggling behaviorally are much less villanized by staff who can now better recognize the effects of trauma-based behavior and effective interventions. Our flexibility in working with each child is now endless and not encumbered by many rules or the guidelines of a behavioral incentive program. While one year is a very brief time to look at evidence of change, we do have three indicators that show great promise. The first is a dramatic reduction in restraints over our previous history.

9 The chart attached as appendix 1 shows our restraints, agency-wide, over a five year period. The red line is the statistical trend line based on all five years. The black line is the trend line based upon only the years before CARE was initiated, and then projected forward. Most important is the consistently low numbers over the last year that are falling to levels lower than any time in the five year period. When restraint numbers are dramatically lower, they are often accompanied by an increase in other critical indicators such as police calls, arrests, AWOLs and property damage. In the last year, however, all of these other areas are also down. The second piece of evidence was in comparison data produced by the Managed Care Partnership comparing critical indicators between like agencies over the last nine months. Waterford Country School is one of four agencies of similar size providing residential treatment to children with psychiatric issues. The Partnership just released its third quarter data showing how the agencies compared in four categories of critical indicators. Their data showed the following: AWOLs: Number of incidents based upon a common number of bed days per child: Waterford Country School 0.3 Comparison Agency Comparison Agency Comparison Agency Police or Emergency Psych Services calls based upon a common number of bed days per child. Waterford Country School 0.5 Comparison Agency 1 0.4

10 Comparison Agency Comparison Agency Arrests based upon a common number of bed days per child. Waterford Country School 0.1 Comparison Agency Comparison Agency Comparison Agency Restraints based upon a common number of bed days per child. Waterford Country School 2.6 Comparison Agency Comparison Agency Comparison Agency The third area of information is in the results of a pre and post test called the Organizational Social Context out of the University of Tennessee. The pretest was given in November of 2008 before any CARE training or orientation began. The second was given exactly two years later or one year following the official implementation date. In the second test, there were three findings of note: The entire Agency profile was almost identical to the pre-test. As climate takes years to develop and culture takes 3-5 years to develop, what is of note is the absence of any deterioration in any of their seven areas of measurement: rigidity, proficiency, resistance, stress, engagement, functionality and morale. Given the extent and quickness of the program change, some deterioration would seem likely, but none appeared.

11 The supervisors showed growth (one standard deviation or more) in two areas, proficiency and engagement, and no deterioration in any other areas. This would indicate a likelihood of improved feelings of competence and feeling more effective in their work. The Agency leadership also showed growth in the same two areas as the supervisors and also achieved scores in three areas above the 90 th percentile: proficiency, functionality and engagement. They also showed a one standard deviation improvement in stress level. As culture and climate improvement is a top-down process, it would appear promising that the initial improvements in leadership will likely result in a future improvement with direct care staff. Conclusion It was both good fortune and fate that Waterford Country School was seeking out Cornell University to help with restraint reduction, at a time when Cornell was piloting a new curriculum for working with children in congregate care. Our trust in the work of Cornell and the quality of the research and CARE curriculum led to a leap of faith moving us from long-standing and trusted ways of treating children to a new approach. By all accounts, thanks to the implementation of CARE, Waterford Country School is now at the beginning stages of an Agency culture and climate shift that will lead us toward better outcomes for the children and will move our Agency from good to great.

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