UMASS Department of Psychiatry Central Massachusetts Communities of Care Jessica L. Griffin, Psy.D. Eugene Thompson, MSW, MSP

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1 Sustaining Evidence-Informed Practice in System of Care Using Trauma-Focused Cognitive Behavioral Therapy: Training, Coaching, and Evaluation Workshop Session #3 UMASS Central Massachusetts Communities of Care Jessica L. Griffin, Psy.D. Eugene Thompson, MSW, MSP Family Continuity Program, Whitinsville, MA Craig Maxim, LMHC

2 Goal of TF-CBT Initiative To import an evidence-based practice that best meets the need for effective, culturally competent traumabased services for children and families in the Central Massachusetts region in need of services. 2

3 The CMCC Project Juvenile Justice focus: Prevention and Diversion Regional gap in evidence-based treatment of trauma Goal: To directly address clinical treatment effectiveness 3

4 Central Massachusetts Communities of Care Geographic Area Excluded 11 4

5 Family Continuity Program Mental Health agency serving Central and Eastern Massachusetts 6 outpatient clinics $13,000,000 annual revenues 300 employees Whitinsville Clinic $1.4 million in revenues providing services throughout Central Massachusetts. 12 staff clinicians and 18 fee-for-service clinicians 5

6 Why TF-CBT?

7 Trauma Focused Cognitive Behavioral Therapy (TF-CBT) *Handout* An EBP developed by Judith Cohen, M.D., Anthony Mannarino, Ph.D. & Esther Deblinger, Ph.D. SAMHSA Model Program, Kaufman Best Practices Most rigorously tested treatment for traumatized children (multiple Randomized Controlled Clinical Trials) 7

8 General Overview of TF-CBT 12 to 18 sessions Components-based model (e.g., PRACTICE) Parent/caregiver role integral part of treatment Structured yet flexible treatment approach Individual child sessions, individual parent sessions, parent-child joint sessions Variety of tools and techniques used 8

9 General Overview of TF-CBT: PRACTICE P sychoeducation & Parenting Skills R elaxation A ffective Expression and Regulation C ognitive coping T rauma Narrative & Cognitive Processing of TN I n Vivo Gradual Exposure C onjoint Parent-Child Sessions E nhancing Safety and Future Development 9

10 An Evidence-Based Treatment Demonstrated improvements in variety of emotional and behavioral trauma-related symptoms in children Improved parental factors Used with variety of traumatic experiences 10

11 Goals for Implementation To train clinicians with fidelity to the treatment model To import TF-CBT into individual mental health agencies in a sustainable way 11

12 Pre-implementation Phase *Handout* Research options for evidence based practices Work with stakeholders to select appropriate evidence based treatment Select participating mental health agencies Secure clinical trainers - national and local Partner with payers / Managed Care Entities (MCE s) Develop plan to evaluate treatment effectiveness and fidelity of practice 12

13 Lessons Learned Allow a lot of time for pre-implementation processes (planning, preparation, communication, manuals, etc.) Administrator in charge must have line authority over trainees and be supportive of implementation. Assure provider agency readiness for change. Get signed commitments from agency administrator(s) and trainees regarding expectations. 13

14 Implementation Phase Began with 7 mental health clinics in 2006 Currently, have 3 mental health clinics with sustainable capacity for TF-CBT 14

15 Lessons Learned Allow for attrition, i.e., plan for a fair number of clinicians (and clinics) to drop out. Payment/stipends for staff training time, lost revenue, supervision time, and coaching are very important at start-up. Stipends/compensation were not as necessary after first rounds of training. Identify and grow your own local trainer from the beginning.

16 Implementation Phase Clinical Training Networking Luncheons Trauma-informing Trainings Administrative/Evaluation Training 16

17 Clinical Training *Handout* Online TF-CBT Training Training by National/Regional Experts Initial 2 day Basic Training Follow-up/Advanced 2 day Training Manuals provided to each clinician Bimonthly consultation calls with national experts and telephone support with regional trainer Coaching visits Networking luncheons Train the Trainer/Supervisors Training 17

18 Lesson Learned Timing is critical. Take advantage of momentum after clinical trainings. Administrative training, family enrollment needs to be done in a timely fashion.

19 Coaching Visits Held monthly at each site TF-CBT trainer and TF-CBT evaluator attended coaching visits Clinicians utilized time to problem-solve difficult issues arising in treatment Emphasis on fidelity to model Supervisors began meeting with TF-CBT trainer/evaluator separately 19

20 Lessons Learned Ongoing support/coaching is essential: Start coaching visits in month following first training Face to face, hands on Contact keeps project on providers radar screens and better ensures fidelity given competing projects and priorities. 20

21 Networking Luncheons Unique opportunity for collaboration and discussion across agency boundaries Special topics presented (e.g., Secondary Trauma; Data and Outcomes; Cultural competence) Q&A sessions: how are we doing? Feedback used to improve outcomes/satisfaction (Ex: consultation calls) 21

22 Lessons Learned Consultation calls did not work as well as expected in initial courses of training. If using consultation calls, structure is critical. Don t underestimate the importance of taking care of people in little ways. Food can go a long way. 22

23 Train the Trainer/Supervisor Curriculum developed based on commonly occurring training issues Differentiation between Trainers and Supervisors ½ day training for Clinical supervisors/trainers, followed by monthly meetings as adjunct to site coaching visits Mentoring for clinic site trainers doing training

24 Lessons Learned A supportive supervisor/trainer within the agency is essential for sustainability. The supervisor must know the model to effectively supervise practitioners. Start training supervisors/trainers from the beginning.

25 Trauma-Informing Trauma Informing Training Collaborative Local trainings to trauma-inform community and increase referrals for TF-CBT Pediatric/Mental Health groups Child Protection Probation/Courts Schools Family Centers Built into FCP trainings

26 Administrative/Evaluation Training Initial consultation with liaisons Training (1/2 day) Project overview Evaluation UCLA PTSD Index/Fidelity checklists National Evaluation Training process and expectations/certification Reimbursement procedures Implementation Binder 26

27 Lessons Learned Many clinicians are fearful of research and evaluation. The Administrative/Evaluation development process takes longer than you might expect.

28 Fidelity to the TF-CBT Model Balancing fidelity with flexibility Brief Fidelity Checklist

29 Lessons Learned Fidelity needs to be monitored from the beginning. It may be necessary to contract with clinicians or have written expectations about commitment to ongoing training.

30 Clinicians Trained to Date *Handout* (n=112) Total Clinicians Attending at Least (1) TFCBT Clinical Training (112) Facilitator: Mannarino & Cohen Facilitator: Griffin Sept 2006 Basic (n=47) May 2007 Advanced (n=7) 32 returning Jan 2008 Basic (n=10) 4 returning July 2008 Basic (n=22) 9 returning March 2009 Advanced (n=4) 23 returning Jan 2010 Basic (n=22) 5 returning

31 Lessons Learned Junior (less-seasoned) therapists do better implementing TF-CBT than do highly seasoned therapists. Always have a back up plan. 31

32 Enrollment 76 youth enrolled to date 57% female, 43% male 93% English speaking, 7% Spanish speaking 77% White, 1% Native American, 1% Black or African American 20% Hispanic/Latino Average age: yrs 41 youth enrolled in Outcome Study to date 81% of eligible are enrolled in Outcome Study

33 Youth and Caregiver Outcomes

34 Findings From CMCC National Evaluation Study of TFCBT Youth (n=41) Voluntary study offered during intake to all TFCBT youth who meet criteria for the study Study interviews families every 6 months for up to 36 months and continues after services end 81% of all youth eligible for the study are enrolled 91% retention rate for TFCBT youth enrolled in the study

35 Measures: Youth & Caregiver Outcomes Change from baseline to 12 months in: Youth Symptoms and Behavior: CBCL (6-18 yrs) Youth Functioning: Columbia Impairment Scale Caregiver Stress: Caregiver Strain Questionnaire Paired sample t-tests were conducted to assess change over time from intake to the 12-month interview

36 RESULTS Statistically Significant Improvements Were Found In: Youth symptoms and behavior problems Internalizing (depression) Externalizing (acting out/aggression) Total Problems Youth functioning Problems at home, school & in the community Parent stress and strain Strain associated with caring for a child with complex needs

37 Youth Functioning: Comparison of Baseline to 12M followup CBCL subscales (n=26) Baseline 12M Internalizing (p<.001) Externalizing (p=.001) Total Problem Score (p=.001)

38 Youth Impairment: Results of Baseline to 12M Follow-up CIS (n=26) B 12M 0.00 CIS Total Score (p=.013)

39 Caregiver Strain: Results of Baseline to 12-month Follow-up Global Strain: CGSQ (n=26) (p=.003) B M

40 Lessons Learned Feedback loops for data really can increase clinical trainee motivation, willingness to hang in there, and ultimately improve outcomes. Present data to clinicians/supervisors/ administrators get the results back to the clinics in a timely fashion to reinforce the importance of data collection. It makes research real for clinicians. 40

41 What are training costs? Cost components: Trainers: External/national-level trainer Range $1,500-3,000 per day per trainer plus travel/lodging Clinical/supervisory staff time Daily salary rates plus lost productivity/revenue: Range: $ per day, per FTE Training materials: Published Training Manual, Training Binders, food, space costs: Range: $ for one-day training; $85-130, two-days. Other e.g., CEUs (Continuing Education Units) Range: $500-1,500 per year. Training manager/organizer/coordinator (highly variable) 41

42 One Clinic s Staff / Lost Revenue Costs (Family Continuity Program) 10 hour online training for all staff = $2,600 Basic Clinical training (8 salaried clinicians,3 fee-forservice clinicians, 2 supervisor/admin.) = $5,700 Advanced training (6 clinicians and 2 supervisors) = $3,760 Supervisors Training, 2 supervisors = $ coaching visits = $2,500 Total start up annualized cost = $14,760 * * Does not include costs for trainers, materials, etc.

43 Lessons Learned Start-up training costs are substantial - a major barrier to implementation of EBP s Approach and include payers at front end to assure that if you build it, they will pay Negotiate procedural and rate incentives. Highlight evidence and report outcomes to payers/mco s Develop billing procedures - track billing/collections 43

44 Our Final Lesson Learned What began as a treatment issue (i.e., addressing untreated trauma) grew into a systems change process.

45 Acknowledgements We would like to thank: SAMHSA, for funding this SOC initiative Linda Foss-Khuu, MS, MPH for her role in this project as evaluation manager from 2006 to 2010 Melodie Wenz-Gross, Ph.D., Director of Evaluation for CMCC Laurel Post, Administrative Assistant to Dr. Griffin

46 Contact Information Jessica L. Griffin, Psy.D., Assistant Professor of Psychiatry and Pediatrics, UMASS (508) Gene Thompson, MSW, MSP, Assistant Project Director/TA Coordinator, Central MA Communities of Care (508) Craig Maxim, LMHC, Program Director, Family Continuity Program (508) x

47 Discussion 47

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