This document was peer reviewed through the NWI. Supporting Wraparound Implementation: Chapter 5d.6 EMQ Children & Family Services: Transformation from Residential Services to Wraparound

F. Jerome Doyle Eleanor Castillo Laura Champion Darrell Evora

EMQ Children & Family Services

Introduction MQ Children & Family Services (aka Eastfield Ming Quong) Eis a private, not-for-profit community-based organization that provides a wide range of services, from addiction pre- vention to wraparound and Rate Classification Level (RCL) 14 group home care (aka residential treatment services), in four major counties throughout California: (a) Santa Clara, (b) Sacramento, (c) San Bernardino, and (d) Los Angeles. It also provides foster care services in 20 other counties. The agency is over a century old, founded in 1867 with roots as an orphanage (Home of Benevolence, later known as East- field’s Children Center) and a rescue mission for Chinese girls (the Presbyterian Mission Home later known as Ming Quong) founded in 1874. In 1970, Jerry Doyle became Executive Director of East- field Children’s Center. At that time, the agency had an an- nual budget of approximately $300,000 to provide residen- tial treatment. In 1987, Eastfield and Ming Quong merged to become Eastfield Ming Quong. Prior to becoming the first wraparound provider in California in 1994, EMQ operated 130 RCL 14 residential treatment beds, at a cost of $95,000 per year per child. The most common primary diagnosis was related to disruptive behaviors (47%), with some type of de- pressive disorder as the second most common. The outcomes for these youth, after an average of 18 months of service, reflected the general “treatment as usual” outcomes. Today, residential treatment revenue represents 5% of a $55 million annual revenue stream, as compared to 72% of a $12 million annual revenue stream prior to the implementa- tion of wraparound. The purpose of this article is twofold:

The Resource Guide to Wraparound Section 5: Supporting Wraparound Implementation

1) to present a case study of how a child-serving events, EMQ underwent a fundamental reinven- organization transformed itself from residential tion, or what is referred to by Nadler and Tushman to innovative, community-based services; and 2) (1995), as a reorientation, “a fundamental redefi- to share issues revealed in the process of imple- nition of the enterprise—its identity, vision, strat- menting wraparound. The article contains three egy and even its values” (p. 26). In a reorienta- major sections including Introduction, Current tion, the organization must change the definition Operations, and Tips to Implement Wraparound, of its work, the attitudes of its people, its formal as well as a final section that includes Lesson structures and processes, and its culture. Learned. Throughout this article, we will reflect Embarking on a New Path. Under the leader- on the significant systems change required to im- ship of Jerry Doyle and Rick Williams (Chief Operat- plement wraparound. ing Officer during the most tumultuous pe- Part 1: From Residential to riod of the process), Community Based Care the agency consulted with Michael Doyle, Attempt to Grow a nationally promi- In a reorientation, Residential Treatment nent expert in the the organization Initial County Partnership. In the course of change management the 1987 merger, EMQ collaborated with the Santa and consensus build- must change the Clara County Executive and local Social Service, ing process, to lead definition of its Juvenile Probation and Mental Health Agencies to a visioning process work, the attitudes assess their need for residential treatment beds which would result and arrived at an agreement that would make in the fundamental of its people, its EMQ’s 130-bed residential treatment program reinvention of the formal structures available exclusively to referrals from Santa Clara then-123-year-old and processes, and County. EMQ accepted any child the County re- organization. Existing ferred to the residential program. In return, the assumptions about its culture. County provided additional funding to meet the the business were set mental health needs of all the children in the aside so as to start program, as the basic residential or group home a visioning process rate structure covered only the care and supervi- from a blank slate sion of the children. Initially, the agreement met (see Doyle, 1986). the respective parties’ needs. However, review The change and renewal process began with a of the program’s outcomes revealed that while self-assessment of strengths and weaknesses. some children seemed to benefit from the -resi The second step was an environmental scan- dential program, for many others, the gains were ning process which included dialoguing with all short-lived once they returned home. Often, this customers, conducting market research, review- was due to the complex family needs that were ing trends in the children’s mental health and left unaddressed by the residential stay, including child welfare fields, and benchmarking services siblings with significant emotional and behavioral in an effort to find more effective approaches to challenges. serving children with serious behavioral and emo- tional disturbances and their families. Through Private Insurance. For a brief period in the this benchmarking process EMQ learned about early 1990’s EMQ explored the possibility of serv- wraparound from some of the early pioneers of ing children whose treatment could be covered the wraparound movement including Karl Dennis by private insurance. As the trends suggested that (Kaleidoscope Program, Chicago), John Vanden- the managed care environment was likely to im- berg, Ph.D. who led the Alaska Initiative wrap- pact both the public and private sectors in Cali- around program (see Burchard, Burchard, Sewell, fornia, the organization realized that it was on & VanDenBerg, 1993), and John Burchard, Ph.D., an unsustainable course. With the confluence of

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who had developed a wraparound program in Ver- Persistence in Creating Systemic Change. Im- mont (see VanDenBerg, Bruns, & Burchard, 2003), plementation of wraparound is more than simply and with whom Richard Clarke, EMQ’s Research starting a new program. Successful implementa- Director at the time, had worked. Simultaneously, tion requires a major systems change effort that EMQ also codified its values and beliefs with an affects and is affected by all levels of the services end product of an organizational Values Constitu- system. In any social system, 2.5% of the individu- tion, which would guide the work and behavior of als are innovators and 13.5% of the individuals are the organization and its employees. This process early adapters to change (Rogers, 1995). More- involved staff at all levels of the organization. over, if a heterogeneous 5% of a social system fun- The next step in the change process was to damentally shifts its culture, fundamental change create a vision of the desired future which was will occur in other areas of the system (Rogers, congruent with the result of the self assess- 1995). ment, environmental scan, and Values Constitu- With EMQ’s experience, it took four years to tion. It was proposed that a visioning approach create significant systems change. Initial efforts be utilized, emphasizing a future ideal state, and then creating a plan to reach that state. A growth and renewal strategy was then developed and a change architecture was designed to move the organization to be more wraparound focused and less dependent on residential services.

Transformation from Residential Services to Wraparound Creating a wraparound Funding Source. In 1991, there was no funding structure for wrap- around in California. The County agreed to con- tinue to pay EMQ the same 60% share of the group home rate that it would otherwise fund to have the same children in the residential program. In addition, EMQ worked in partnership with the county in an ultimately successful four-year ef- fort to secure passage of legislation (AB2297) concentrated on identifying and working with in- providing that the state’s 40% share of the group novators and early adapters that would support home rate was made available to help fund wrap- the change. This included the presiding judge of around, and to leverage potentially available fed- the dependency court at the time, the Honorable eral funding streams including Title XIX (Medicaid Len Edwards, who became an early champion of federal mental health funding; known as Medi-Cal the wraparound process. in California) and Title IV-E dollars (federal reim- As change is dynamic, it is important to ad- bursement to states for the board, care, and su- dress local, state, and national levels concurrent- pervision costs of children placed in foster homes ly. This includes extensive wraparound training for or other types of out-of-home care under a court all employees within the organization, manage- order or voluntary placement agreement). To en- ment and line staff of the Social Services Agency, sure cost neutrality to the County, EMQ was paid and the Mental Health Department, the District the appropriate share of the group home rate less Attorneys, Public Defenders, and County Counsel. any concurrent out-of-home placement costs to Through this process, additional champions for the County for children in wraparound. Although the change process will emerge. Partnerships with each county varies in application of the 60-40% national wraparound experts may help generate share, this continues to be the primary financial support for the major systems changes necessary structure to fund wraparound in California. to provide training.

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Policy and Legislation: The Four-Year Strug- the group home rate for each wraparound slot. gle for Funding. Having an agency reserve helped In response to a class action lawsuit filed in in the period of financial crisis. While promoting 2002 that challenged California’s practice of con- wraparound on all systems levels, EMQ closed 100 fining at-risk youth to hospitals and large group residential beds over an 18-month period, result- homes instead of providing services to enable ing in a precipitous drop in annual revenue from them to remain in their homes and communities, $12 million a year to $8 million a year. EMQ had Judge A. Howard Matz ordered the state to pro- fixed overhead costs including bond payment ob- vide wraparound and therapeutic foster care to ligations which could not be eliminated, and for any child in or risk of entering California’s foster the first time in over 20 years, EMQ had serious care system. The Katie A. vs. Bonta litigation (Ka- and growing budget deficits. tie A. et al., v. Diana Bonta et al., 2006) provides Meanwhile, EMQ worked with the California another avenue through which wraparound should Department of Social Services (CDSS) and elected proliferate across California. officials on statewide wraparound legislative pro- posals to allow for funding of wraparound as an Part 2: EMQ Wraparound alternative to group home care. However, there Operations Today was enormous resistance to the legislation from Today EMQ serves approximately 6,000 youth the group home industry. Ultimately, the first two and families on an annual basis. Approximately attempts at legislation failed, but EMQ persisted 350 of those youth receive wraparound and an- in working with various legislators (e.g., Senator other 250 receive services from programs based John Vasconcellos, Assemblymember Cunneen) on system of care and wraparound principles. Al- and state and county leaders (Eloise Anderson, though the agency has over ten years of experi- Director of CDSS) that eventually resulted in suc- ence as a wraparound provider, the local system cessful legislation (AB2297, SB163) that provided of care in which it operates vary significantly and state and county funding for wraparound. have made implementation of services a chal-

Wraparound Growth in California lenge. Accordingly, it is critical to continually en- gage in positive systems change efforts focused Wraparound in California has increased rap- on each of the counties served, and on the state idly since 1994. By 2000, seven other counties as a whole. were providing services through some version All of EMQ’s wraparound programs serve an of the wraparound process. Five years later, 29 ethnically diverse group of children between 5 counties were providing wraparound. In FY2007, and 18 years of age who meet Medi-Cal criteria Proposition 63 is projected to generate $1.6 bil- for services. Prior to referral to wraparound, many lion in new funding for mental health services for of these youth received traditional mental health children, adults, and older adults through a 1% services, such as residential treatment, day treat- tax on personal income above $1 million a year. ment or intensive outpatient. The current aver- Within three years of the passage of Proposition age length of stay is 16 months, with a range of 9 63 in November 2004, the Mental Health Services to 24 months. Act (MHSA) requires every county to implement In the rest of this section, we present some an SB163 wraparound program for youth and their tips for wraparound implementation based on families, unless the county provides “substan- EMQ’s experiences reconfiguring itself to support tial evidence that it is not feasible to establish a service provision via the wraparound model. wraparound program in that county.” (See http:// www.dmh.cahwnet.gov/MHSA/docs/meeting/12- Tips to Implement Wraparound 17-2004/Mental_Health_Services_Act_Full_Text. pdf.) In effect, wraparound will be available as an Tip #1: Commit to Being a Continual Learn- EMQ uses several tools to sup- alternative to group home care throughout Cali- ing Organization. port continual improvement: fornia. Furthermore, these programs will have ac- cess to the state and county foster care share of 1. Formal change management techniques to

 Chapter 5d.6: Doyle, et al.

enhance the success of an implementation a forum for the pod that will impact large systems or the cul- members to ex- ture of an organization. Such tools (e.g., change ideas to bet- Business Case for Action, sponsorship con- ter meet the needs tracts, etc.) are widely applied in corpo- of children and fami- rate organizations and can also be applied lies. The structure As mainstream in social service organizations. of the pod meeting graduate schools 2. Consistent data collection via various out- reinforces the needs- tend to emphasize driven approach of comes measures and an electronic health traditional clinical record system. It is critical to have an in- the wraparound pro- frastructure that includes identified staff- gram and thus differs practices that focus ing with specific responsibilities to coordi- from most traditional on the medical nate outcomes and evaluation efforts. clinical team or staff meetings. model as opposed 3. A Research Advisory Council composed of to a strength renowned subject experts. The purpose of Tip #3: Provide the council is to provide an objective re- On-Going Training based, family- view of current outcomes evaluation and and Mentoring for centered practice, Staff. Successful recommend research based on their cut- training is a ting edge information from the field. Such CPMs have sophis- a relationship provides a vehicle for col- ticated facilitation crucial component laboration between universities and local skills. They are re- of the CPM’s agencies that provide direct services. sponsible for train- ing Pod members in responsibility. Tip #2: Management Infrastructure Needs wraparound philoso- to Support Wraparound Implementation. A Li- phy and practices. As censed Clinical Program Manager (CPM) is responsi- mainstream graduate ble for both clinical and administrative supervision schools tend to em- of services provided by the Masters-level family phasize traditional facilitators (FF), family specialists (FS), and fam- clinical practices that focus on the medical model ily partners (FP), all of whom serve a number of as opposed to a strength based, family-centered families. Facilitators conduct the child and family practice, training is a crucial component of the teams (CFT) while family specialists work directly CPM’s responsibility. In general, training and with the children and Family Partners provide the coaching is an on-going process that should en- support for parents. Under the supervision of the compass all aspects of one’s responsibility. Table 1 CPM, this group of facilitators, family specialists, (see following page) provides a sample of current and a family partner comprise a pod. training topics. Child and Family Team (CFT). The pod and Tip #4: Continually Improve Wraparound CPM are the two basic organizational structures Implementation. In the effort to continually pro- that support the CFT. The CFT is the primary unit vide best practices, the following components are involved in implementing the wraparound process. included to enhance the wraparound process and The team is comprised of the child, caregivers, subsequently enhance outcomes for children and other family members, clinical professionals, and families. any “natural” (non-clinical professional) members and is responsible for identifying, facilitating, and Functional Behavior Assessments (FBA). As monitoring services for the child. described by O’Neill, et al. (1997), the purpose of a functional assessment is to improve the ef- Pod Meetings. The teams of clinical profes- fectiveness and efficiency of behavioral interven- sionals work in a group to provide and manage tions by serving as a data-collection tool. The the wraparound process. Pod meetings have two processes employed provide an analysis that may major aims: building staff morale and providing reveal the children’s patterns of behavior, iden-

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tifying specific triggers for undesirable behaviors This intervention takes the form of a proactive be- (antecedents) and the needs that the behaviors havioral support plan that contains the educative fill (consequences). Using this information, the components and means of communication with staff, particularly the family specialists, create a the child, and lays the groundwork for evaluating behavioral support plan whereby an intervention the outcomes of the plan (Ingram, Lewis-Palmer, is proposed based on the hypothesized function & Sugai, 2005). of the behavior, and youth are taught alternatives Conograms. A conogram is a pictorial illustra- to the target behavior that fulfill the same need. tion of relationships in an individual’s life. (See

Table 1. Wraparound Program Sample Training Topics

General Topic Description Category Orientation Job Expectations Introduce staff to performance- and outcomes-based work, and review job responsibilities for each position to support wraparound and program goals On-Call How to respond to family emergencies using wraparound values and the safety plan Legal and Confidentiality and Responsibilities and procedures for confidentiality and Ethical Abuse Reporting/ mandated reporting, and how these issues are handled HIPAA in the wraparound process and community setting Financial Documentation How to bill and document billable services for (Progress notes) wraparound Flex Funding Appropriate ways to utilize a funding stream to enhance services Wraparound Wraparound Overview Historical overview of wraparound and exploration of (day 1) wraparound values Wraparound Overview How to implement the 10-step domain planning process, (day 2) and the roles and responsibilities of CFT members Community Access How to implement timely, relationship-based resources to meet needs in multiple life domains Safety Planning How to facilitate the development and design of dynamic and responsive safety plans and how to implement them in the family, home and community Interventions Connectedness How to visually map out primary connections for Mapping children in CFTs Family Finding The importance of permanency and durable connections for children over time; tools and skills for implementing family finding Outcomes Child and Adolescent CAFAS ratings and integration of the CAFAS into the Functional Assessment wraparound plan Scale (CAFAS; Hodges, 2000)

 Chapter 5d.6: Doyle, et al.

Figure 1. Sample Conogram

Grandparents paternal (and older) grandparents foster Generation maternal grandmother bipolar grandparents

mat. ex ex music aunt foster foster teacher Parents’ pat. mother mother Generation therapist uncle mat. bio uncle current bio foster fa. mo. father

Siblings’ 16 Generation (excluding peers) 13 15 5 8 13 20 foster bio siblings foster sibling sibling

Peers 20 girlfriends boyfriend

Figure 1.) Red lines of connection indicate who members who have lost connection with the child loves whom, blue lines indicate blood relations, for various reasons. The process is a combination green lines indicate who is teaching whom, and of conversations, chart reviews, internet searches yellow lines indicate spiritual connections while and travel, all in the interest of re-establishing purple lines capture cultural connections. The broken connections and developing potential per- EMQ connectedness diagramming process is de- manency for these children. signed to be used collaboratively with children Professional Parenting. A professional parent and families to explore various relationships that is someone, often a foster parent with special- might not otherwise be discovered. This process ized training, who will support the youth through attempts to capture the various types of rela- the planning and transition process and help them tionships in a manner that fosters engagement, move on to their permanent home. The profes- empowerment, genuine inquiry, and the desire sional parent provides a stable, caring and struc- to truly understand the intimate lives of children tured environment for the youth while meeting and families. This connectedness map provides all community care licensing foster care require- the basis of ongoing work for the team that sup- ments. ports the child. Independent Living Skills (ILS). Family spe- Family Finding. Family finding, pioneered by cialists provide individual and group ILS training Catholic Community Services of Western Washing- (e.g., money management, household chores, ton (CCSWW) in Tacoma, WA, is a process to iden- employment training, community safety, etc.) for tify or locate a dependent child’s biological family

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the youth as needed to meet their goals to better ganization. Prior to the implementation of the prepare them for adult life. wraparound philosophy (e.g., strengths based) Tip #5: Wraparound Can Be Used to Meet and practices (e.g., services in the community), Different Target Population Needs. Although both programs were well below the program cen- wraparound in California was designed as an al- sus with lengths of stay longer than anticipated. ternative to high level residential care, the wrap- Furthermore, staff attrition reflected that of around principles can be applied to various target similar settings in the nation (Ben-Dror, 1994), populations. For example, in 2001 EMQ adopted and productivity was half of the expected target. the wraparound principles as the basis for service Since the implementation of the wraparound phi- re-design and provision in two other clinical ser- losophy and practices, both programs now meet, vices: System of Care (SOC) and Matrix, as neither if not exceed, the program census with lengths program was achieving desired outcomes such as of stay half that of pre-implementation. Further- those being demonstrated by the agency’s wrap- more, staff attrition is well below the 15% target, around program. Despite its name, “System of and productivity has doubled. Care” (which reflected a particular mental health Because these three levels of care are avail- funding stream in California prior to 2003), the able within a single agency, recipients of services SOC program was serving fewer than 35 children have the benefit of a seamless transition between in a traditional, clinic-based therapeutic model. appropriate levels of care, decreasing or increas- The Matrix program was originally designed in ing service intensity given the child’s behavior 2001 as an alternative to residential placement and/or level of functioning and their caregivers’ for older adolescents in the Santa Clara County ability to address the challenges. Families in this Children’s Shelter. Some youth were living in con- program to do not have to be concerned about be- gregate care residential treatment while others ing referred elsewhere to have their needs met. were living in the community with therapeutic Tip #6: Continually Evaluate Treatment support. The residential component was fraught Outcomes and Process Outcomes. In addition to with the usual difficulties inherent in congregate analyzing treatment outcomes, EMQ developed care for this population of high-risk, older, street- the wraparound Supervisor Adherence Measure savvy adolescents. (W-SAM; Castillo & Padilla, 2007). Developed on Table 2 illustrates the positive impact of wrap- the same premise as the Multisystemic Therapy around on different target populations in an or- Supervisor Adherence Measure (SAM; Henggeler,

Table 2. SOC and Matrix Process Outcomes

Indicators SOC Matrix

Pre-Wrap Post-Wrap Pre-Wrap Post-Wrap Average Census/ 35/50 145/160 13/20 27/24 Capacity Length of Stay 18 months 10 months 22 months 11 months

Intensity of 1 hr/wk 3-5 hr/wk 3 hrs/wk 5-10 hrs/wk Service Staff Attrition 50%/yr 5%/year 60%/yr 5%/year Rate Staff Productivity 50 hrs/mth 100 hrs/mth 43 hrs/mth 100 hrs/mth

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Schoenwald, Liao, Letourneau, & Edwards, 2002), on appropriate use of flex dollars for all stake- in that the supervisor plays a critical role in main- holders. The stewardship plan should include: (a) taining fidelity, the Wraparound Supervisor Adher- specific flexible funding training for staff; (b)a ence Measure (W-SAM; Castillo & Padilla, 2007) “Stewardship of Flexible Funding” protocol to be is a 40-item questionnaire that rates the super- shared with each new family and referring work- visor’s fidelity to the wraparound principles and ers; and (c) job performance expectations for the practices from the facilitator’s perspective on a 5- direct care staff that families are provided with point Likert scale (1- Never to 5- Almost Always). a viable transition plan from the use of these flex Currently, the tool is in its infancy stage and fur- funds to accessible community resources. ther analyses are necessary. However, there ap- Lesson #3: Need for an “In-Vivo” Coaching/Su- pears to be a trend in the relationship between pervision Model as opposed to a traditional office the supervisor fidelity scores and positive process based supervision model. The wraparound service and treatment outcomes. For example, the trend delivery model and underlying principles require suggests that higher fidelity scores tend to be cor- staff to work in the community, and to provide related with planned discharges. very specific, individualized care. The traditional supervision approach of meeting with staff in the Part 3: Lessons Learned office during the typical work week hours is not Operational Lessons. Below are only a few op- sufficient to support staff in providing high qual- erational lessons learned over a decade of wrap- ity wraparound. In a coaching/support model of around implementation in California. community-based services supervision, supervi- sors are required to go out into the community to Systems Practices Impact Ser- Lesson #1: observe the provision of the wraparound process vice Provisions. When implementing wraparound, and be available 24/7. there needs to be an effective system in place for addressing systems issues, particularly as they Lesson #4: Need for Evidence Based Practices manifest at the direct care level. Without objec- (EBP) to Support the Overall Effectiveness of the tive data, much less a forum to address these con- Wraparound Process. Promising and evidence- cerns, sometimes idiosyncratic events or issues based practices can enhance the wraparound are inappropriately generalized to the program process. For example, when the family special- rather than viewed as a symptom of a larger sys- ists are trained to utilize Functional Behavioral tems issue. With no formal forum to address the Assessments and Positive Behavior Support plans, system’s issues, the problem is likely to continue the amount of time they need to spend with the to rear itself in direct service situations. Regu- children decreases as their work is more effective lar convening of a local community collaborative, in a shorter period of time. Furthermore, given and/or quarterly meetings of managers for each that the majority of our youth have been trau- referring department is recommended. This fo- matized as they have been removed from home rum may address such topics as: (a) review and and experienced some type of trauma, Trauma discussion of program outcomes (including trends Focused-Cognitive Behavior Therapy (TF-CBT; over time); (b) identification and resolution of de- Cohen, Mannarino, & Deblinger, 2006) has been partment concerns or needs; and (c) strategizing used to help achieve more positive outcomes in a and planning. This proactive approach to resolv- shorter period of time. ing systemic concerns may also serve as an inter- Lesson #5: Documentation of Wraparound departmental collaboration to identify current that Emphasizes a Strengths-Based, Youth- and training needs for program and referring depart- Family-Driven Service within a “Medical Model” ment social workers, probation officers, and men- that Focuses on Medical Necessity for EPSDT Re- tal health clinicians. imbursement. Continual training is necessary for Lesson #2: Management of Flexible Funding is staff as they integrate a service delivery model Important. Having a formal flex fund stewardship that emphasizes different aspects of treatment plan from the onset will establish clear guidelines from the revenue streams’ emphasis. Initially staff may struggle to integrate a strengths-based,

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needs-driven philosophy in a system whose fund- system staff, it can be an incredibly rewarding ing stream is pathology based (e.g., Medi-Cal). and rejuvenating experience for both the families For example, documentation may focus on sup- and staff. port activities and capturing the child’s and fami- ly’s strengths, rather than articulating the exten- Macro-Level Lessons sive interventions utilized to intervene with the Lesson #1: The Power of the Visioning Pro- child’s behaviors. Training is essential to illustrate cess. EMQ has learned from experience that a how mental health concerns of the child and fam- well-executed visioning process to fundamentally ily are components of the “behavioral and psycho- transform an organization is extremely powerful. logical domains” of a comprehensive wraparound Allowing people to imagine what could be, rather plan that addresses the various aspects of youth than simply trying to fix what’s broken, involves and families’ lives. engagement of people’s hearts and minds. Lesson #2: Systems Thinking. The introduction and dissemination of wraparound is best under- stood and executed as a major systems change ef- fort, and not simply as the introduction of a new program. Many of the fundamental principles and values of wraparound will directly challenge and confront existing assumptions that are prevalent in many children’s services systems. Fundamental cognitive, attitude, and cultural changes toward parents and about the appropriate roles of various players in the system are imperative at the indi- vidual clinician level and various systems levels. Lesson #3: The Value of Partnerships. Real and effective partnerships, rather than mere “purchaser/vendor” relationships between gov- Lesson #6: The Need for a Significant In- ernment entities and non-profit organizations, vestment in Training and Supervision Can Not Be can have enormous benefits to both parties, as Overemphasized. While values that are core to well as to children, families and the community as wraparound are gaining increasing acceptance a whole. Many leading private sector companies nationally, it is still not a core practice. Assuring who have made a commitment to an emphasis on families’ voice, choice, and ownership of their total quality and continuous quality improvement treatment plan and focusing on strengths as the have learned that it is much more cost effective building blocks for the creation of that plan of- to build long-term partnerships with high qual- ten flies in stark contrast to the pathology-based, ity suppliers, rather than to continuously subject expert-centric medical models that still exist in “vendors” to competitive bidding based primarily many communities and university curriculums to- on cost. The same is true of relationships between day. Subsequently, new and seasoned clinicians government entities and non-profit provider orga- alike require significant education, training and nizations. supervision to support this practice change. Lesson #4: Change Management. It is very Lesson #7: Celebrate Successes and Provide helpful for organizations to consciously think of Consistent Reinforcement. It is important to con- themselves as being in the change management sistently reinforce staff for positive outcomes. business, rather than as in the child welfare or Having a formal forum for such recognition is pow- mental health business. Equipping its manage- erful reinforcement for all stakeholders. Gradua- ment and key staff with state-of-the-art change tion celebrations are a formal means of celebrat- management methodologies and knowledge will ing success. When families share their journey greatly increase the effectiveness of the organi- with the entire wraparound team and referring zation, no matter what environmental challenges it may face. Perseverance and tenacity are criti-

10 Chapter 5d.6: Doyle, et al.

cal, as major systems change is often long and dif- ships. Most non-profit agencies really want to ficult. Establish a culture that embraces change help children and families. Many agencies, with as an opportunity for personal and professional the proper training and support will willingly and growth. perhaps eagerly make the shift from a residential Lesson #5: It’s All about Outcomes. Focus on focus to a wraparound focus if they are given the outcomes, not on cost. Agencies’ commitment opportunity to retain any savings achieved and to to improve the outcomes for children and fami- reinvest those savings to provide additional ser- lies should be the fundamental driver of systems vices for children and families. change efforts. It is true that timing is everything. In the 15th century, Niccolo Machiavelli wrote, It is much better to initiate the introduction and “There is nothing more perilous to undertake, nor diffusion of wraparound at a time when govern- more uncertain of its outcome, than to create a ment funding is relatively stable, rather than in new order of things.” The historical failure of the the middle of a major budget reduction. Other- foster care and mental health systems to effec- wise, there is a very great risk that the primary tively meet the needs of children has been well emphasis will be on cost saving, rather than on documented. We owe it to the children and fami- achieving positive outcomes for children and fam- lies we serve, and we owe it to ourselves, “to cre- ilies. On the other hand, if agencies implementing ate a new order of things.” Although the birthing wraparound are allowed to keep any savings that of wraparound in California has been long and at may be achieved, and to reinvest those savings in times very painful, the results have been worth the provision of new prevention or early interven- the effort. tion services, their motivation to make the change will be greatly enhanced, and the long term sav- References ings will be maximized. American Psychiatric Association (1994). Diagnos- tic and statistical manual of mental disorders Conclusion (4th ed.). Washington, DC: Author. The dissemination of wraparound requires a Ben-Dror, R. (1994). Employee turnover in com- systems change effort as the very nature of wrap- munity mental health organization: A devel- around requires significant systems review, and opmental stages study. Community Mental perhaps systems overhaul. The process not only Health Journal, 30(3), 243-257. impacts an agency, but all systems (child welfare, Burchard, J.D., Burchard, S. N., Sewell, R., & Van- education, juvenile probation, mental health, DenBerg, J. (1993). One kid at a time: Evalua- substance abuse, etc.) involved in the lives of par- tive case studies and descriptions of the Alaska ticipating youth and families’ lives. Accordingly, Youth Initiative Demonstration Project. Wash- implementation of wraparound requires the de- ington, D.C.: SAMHSA Center for Mental Health velopment of effective and collaborative relation- Services. ships with elected officials, public agency leaders at the state and local levels, and key leaders in California Department of Social Services. Children the private and non-profit sectors. and family services. Retrieved April 10, 2007 The shift in cognitive schema about mental from http://www.childsworld.ca.gov/Family- health services cannot be overemphasized. Wrap- Cen_318.htm around should not be viewed as a money saver in California Department of Mental Health. Mental the context of limited resources. Rather, it should Health Services Act. Retrieved May 21, 2007 be viewed as a service to produce better out- from http://www.dmh.cahwnet.gov/MHSA/ comes for the youth and families who have often docs/meeting/12-17-2004/Mental_Health_ times been through a system that may have inad- Services_Act_Full_Text.pdf. vertently hindered quality of life. Organizations Castillo, E. & Davis, L. (2007). Transforming a and all systems should consider the tremendous youth residential program with positive behav- advantage of building real partnerships between ior supports, families, and communities. The government agencies and leading non-profit agen- NADD Bulletin, 10(1), 3-10. cies rather than mere purchaser/vendor relation- Castillo, E., & Padilla, V. (February 2007). Wrap-

11 Section 5: Supporting Wraparound Implementation

around Supervisor Adherence Measure: A pilot. New York: The Free Press. 19th Annual Research Conference Proceed- Scott, T.M., & Eber, L. (2003). Functional Assess- ings: A System of Care for Children’s Mental ment and wraparound as systemic school pro- Health: Expanding the Research Base. Tampa: cesses: primary, secondary, and tertiary sys- University of South Florida, Louis de la Parte, tems examples. Journal of Positive Behavior Florida Mental Health Institute, Research and Interventions, 5(3), 131-143. Training Center for Children’s Mental Health. U.S. Department of Health & Human Services, Doyle, M. (1986). How to make meetings work. Centers for Medicare and Medicaid Servic- New York: Jove. es. Medicaid. Retrieved April 10, 2007 from EMQ Children & Family Services. Retrieved April http://www.cms.hhs.gov/home/medicaid.asp 10, 2007 from http://www.emq.org VanDenBerg, J., Bruns, E., & Burchard, J. (2003). Hodges, K. (2000). CAFAS self-training manual History of the wraparound process. In J. Walker and blank scoring forms [training manual]. & E. Bruns (Eds). Focal Point: A National Bul- Horner, R. H., & Sugai, G. (2000). School-wide be- letin on Family Support and Children’s Mental havior support: An emerging initiative (special Health: Quality and Fidelity in Wraparound, issue). Journal of Positive Behavioral Inter- 17(2). ventions, 2, 231-233. Implementation Management Associates, Inc. Authors About IMA: What we do. Retrieved April 10, F. Jerome Doyle is the Chief Executive Officer of 2007, from http://imaworldwide.com/home. EMQ Children & Family Services, California’s most asp comprehensive mental health agency serving chil- Ingram, K., Lewis-Palmer, T., Sugai, G. (2005). dren and their families, and home to California’s Function-based intervention planning: Com- first intensive wraparound program. In 1996, Mr. paring the effectiveness of FBA function-based Doyle successfully worked with system partners and non-function-based intervention plans. to pass state legislation creating funding for this Journal of Positive Behavior Interventions, 7, program as a demonstration project. This wrap- 224-236. around demonstration project, because of its suc- cessful outcomes, has now been expanded state- Katie A., et al., v. Diana Bontà, et al., No. CV02- wide and is in fact a required program offering in 5662 AHM (SHx), U.S. District Court, Central every county in California. District of CA., (March 14, 2006). Mental Health Services Act, 63 CA Dept. of Mental Eleanor Castillo, Ph.D., is former Corporate Di- Health (Nov. 2004). rector of Outcomes and Quality Assurance at O’Neill, R.E., Horner, R.H., Albin, R.W., Sprague, Eastfield Ming Quong. Dr. Castillo currently is in J.R., Storey, K. & Newton, J.S. (1997). private practice, providing consultation on im- Functional Assessment and program develop- proving outcomes by transforming management, ment for problem behavior: A practical accountability structure, and operations. handbook. Pacific Grove, California: Brooks/ Laura Champion is a licensed Marriage and Fam- Cole Publishing Company. ily Therapist certified in Chemical Dependency Riley, S.E., & Stromberg, A.J. (2001). Report on treatment with 24 years of experience working parent satisfaction with services for Medicaid with children, adolescents, and families with se- youth at community mental health centers in vere behavioral and mental health issues. She is Kentucky. Unpublished Manuscript, Kentucky the Santa Clara County Division Director at EMQ Department of Mental Health and Mental Re- Children and Family Services. She is responsible tardation Services. for program development, assurance of clinical Rogers, E. M. (1971). Communication of innova- quality, leadership and management of eleven tions. New York: Free Press. programs serving over 2,000 children and families annually. Services range from Wraparound and Rogers, E. M. (1995). Diffusion of innovations. System of Care to Residential and First Five. Laura

12 Chapter 5d.6: Doyle, et al. has also been the director of a Chemical Depen- Acknowledgments dency Treatment facility for adolescents and the Maria Azevedo, Executive Assistant Associate Director for a Level 14 residential treat- Cheryl Hilla, Administrative Assistant ment facility. She has successfully implemented Maribel Davis, Administrative Assistant the Wraparound principles into numerous clinical Roberto Favela, LCSW, Vice President of Adminis- service models over the past decade with success- tration ful outcomes for children and families. Darrell Evora is the President and Chief Operating Officer for EMQ Children and Family Services. Dar- rell was previously EMQ’s statewide Wraparound Division Director and was responsible for all as- pects of developing and implementing individual- ized care services and ensuring their clinical qual- ity, effectiveness, and fiscal management. Darrell is a Licensed Marriage and Family Therapist with Master Degrees in both Business Administration Suggested Citation: and Counseling Psychology from the University of Santa Clara. Doyle, J. F., Castillo, E., Champion, L., & Evora, D. (2008). EMQ Children & Family Dedication Services: Transformation from residential services to wraparound. In E. J. Bruns & To my great friend, my spiritual brother, and my J. S. Walker (Eds.), The resource guide to mentor, Michael Doyle, December 21, 1942 - Jan- wraparound. Portland, OR: National Wraparound Ini- uary 29, 2007. tiative, Research and Training Center for Family Sup- -Jerry Doyle port and Children’s Mental Health.

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