CBHI Systems of Care Transcript

CBHI System of Care Objectives Voiceover transcript: Now that you know the basic characteristics and principles of CANS, let’s turn to the Children’s Behavioral Health Interagency Initiative (CBHI) and its System of Care to understand how CANS fits into CBHI values and services. Please review your objectives before beginning.

Rosie D. Lawsuit Voiceover transcript: In 2001, a class action lawsuit against the Commonwealth of Massachusetts argued that the behavioral health services provided by the Commonwealth’s Medicaid program were not well coordinated, were not family centered, and often unnecessarily placed children in restrictive settings. In essence, the plaintiffs demanded that more community based, family centered services be provided. The Court ruled in favor of the plaintiffs in 2006, and the Commonwealth was required to remediate non-compliance by restructuring the children’s behavioral health services provided under Medicaid. The goals were to increase families’ access to services available in their own communities and to create a new array of family- and children-centered services to better meet their needs.

Origins of CBHI Voiceover transcript: In response to the court-ordered remedy, the Commonwealth created an office within the Executive Office of Health and Human Services to manage its implementation. This office was called the Children’s Behavioral Health Interagency Initiative, or CBHI. CBHI was charged with redesigning the children’s behavioral health system to meet the vision of the judge and the agreements reached in the lawsuit. To do that, they reworked the kinds of services that were available through Medicaid (that is, MassHealth), thus changing the way the system provides support to youth and their families. And they established a set of values to guide practice.

CBHI Services Voiceover transcript: The CBHI services listed here began to be integrated in June 2009.

Service Definitions, Performance Specifications, and Medical Necessity Criteria Voiceover transcript: Because the Rosie D. lawsuit concerned compliance with federal Medicaid laws, each level of care was described in terms of service definitions, performance specifications, and medical necessity criteria. Familiarity with the service array allows clinicians to make the clearest recommendations for services that match a youth’s needs.

The Way CBHI Provides Support Voiceover transcript: Before CBHI, there were fewer options for families whose children had serious emotional disturbances. Youth and families often found it difficult to advocate for themselves, and sometimes found it impossible to manage the competing demands, schedules, and goals of treatment providers. Youth who had intensive needs were often in out-of-home settings, far away from their families and communities.

CBHI shifted the child and family to the center of their own care. CBHI broadened the kinds of services that were available, and added intensive care coordination to keep these services working together. The new services provide higher levels of care in the youth’s own community. Collectively, this new structure altered the way MassHealth services look and feel for families with youth who have serious emotional disturbance. In the next video, Hannah Karpman and Sara Belding discuss changes that have occurred as a result of introducing CBHI services.

Video: The Landscape of Services for Children Video transcript: >> And so, one of the things I think about now is just how different the landscape is for kids and families, in terms of mental health services, in the commonwealth. So, can you talk a little bit about that now you're in in-home therapy, what do you think is different? What looks different? >> I think a lot of the services have shifted to be more community-based, which is really powerful for families where - and youth -- because they're working on things in - within the context in which they actually live. Before, there were a lot of kids in residential treatment centers living in really artificial settings, where they were practicing things but there was limited family engagement. So, the caregivers were coming to family therapy once a week, but really weren't in it with the kids. And the expectation was really almost on the kids to do all the changing, and now there's more of an understanding that it's the whole family system that really needs to shift and that the work needs to be done more in the community and in the place where the youth is residing most of the time, and where they're going to hopefully continue to reside, they're not going to have to be institutionalized.

Interactive Exercise 1

Interactive Exercise 2

CBHI Values Voiceover transcript: In addition to the new services, CBHI established five values that guide all service provision. All services will be: Child Centered and Family Driven, Strengths Based, Culturally Responsive, Collaborative and Integrated, and Continually Improving.

CBHI Values: Child Centered and Family Driven Voiceover transcript: Let’s go over each of these values in a little detail. The first value is that CBHI services are driven by the needs and preferences of the child and family, developed in partnership with families, and accountable to families. Planning and service provisions should reflect the family’s perspectives of their needs and strengths, and clinicians should work collaboratively with youth and their families to bring their voices to the forefront of treatment planning. Rather than the treatment being driven by the provider as the expert, “child centered and family driven” means that the family directs their treatment in concert with guidance and support provided by professional helpers. Listen to Hannah Karpman and Sara Belding in the next video discuss the new services in the context of the family-driven value.

Video: Hannah Karpman and Sara Belding Discuss Family Focus Video transcript: >> So, like one of the things you think is different is in the old system, it felt like providers were deciding

what families need and now in the new system, the idea is that families help tell providers what it is actually that they need. >> That providers still are able to maintain that they have a certain amount of knowledge because of their training but that they aren't the experts on the family. The family is the expert on the family and so it requires the expert with the clinical knowledge and then the expert on the actual family to come together and work together to figure out how best to tackle problems. >> So, it sounds like you're highlighting two important differences, one that now services are more community-based; and two, that they're really sort of the entry point as more the family's perspective instead of the system’s perspective of the family.

CBHI Values: Strengths Based Voiceover transcript: CBHI services also are based on the strengths of the youth, their family, and their community rather than focusing solely on their needs or problems. This is a real change in the perspective for many clinicians and families as discussed in the following video by Anthony Irsfeld and Beth Chin.

Video: Beth Chin and Anthony Irsfeld Discuss Strength-Based Treatment Video transcript: >> Anthony, when you're training your new clinicians, what do you suggest to them in terms of how they can talk to families and youth about their strengths? >> Oftentimes, clinicians are trained to go after what's wrong, like the - you know, people come in, things aren't going well and I think most of the time, we're trained to get at what's the problem, what's causing the problem, what's the right diagnosis. And we're trained to be very efficient with our questions and time so we can get at the problem. And I find that a lot of people struggle with strength based work because to ask a parent about what's going well, to get into conversations about the good things, can feel like a bit of waste of time, like I'm - like there's this internal clock I'm not really getting at the real stuff I'm supposed to be talking to. And I find that new staff who are training will, you know, ask a strengths' question but you can also see them just waiting for the parent to get to the end so they can go back and ask a question about the problem. It's like people feel like it's - they're just chatting, or it's not clinical enough. And so, one of the things that we have to do when we train people is to sensitize them to why it's so important to spend time with people talking about strengths. And we really try to have a lot of conversations with our staff about what the effect is on families when you - what they experience when a professional comes into their home and shows genuine interest in their strengths, and how powerfully engaging that can be, how that can lead them to have more confidence in themselves, how it can even provide hope, in some cases. And so, even if the content that you're learning by asking some strengths' questions, doesn't appear immediately relevant to like, well, how does that fit with what I'm supposed to be doing. Or, I'm not quite sure how this story fits with the problem. We try to get staff to relax and not worry about that. The fit can come later and to focus on how wonderful the process can be for families, and what that feels like for families, to be able to have those kind of conversations with professionals. >> That's a really good point because that I find sometimes that the staff might feel like if they talk about the strengths, they're not listening to the problems or the concerns. When I talk to them about focusing on engagement, focusing on engaging with the caregiver, or focusing on engaging with the

youth, that it's almost like an ah-ha moment and then they understand oh, okay, that's how I can fit in these conversations and be genuine about it, and not be, oh, well, let me - just tell me a couple of things you're good at and have it be an add-on to an assessment.

Strengths and Treatment Planning Voiceover transcript: Anthony and Beth also discuss an example of strengths that might be meaningful for treatment planning.

Video: An Example of Strengths Video transcript: >> So we - we're out at a family's house, maybe a second meeting, and we're having a conversation with a mom about her concerns about the kids. And sort of spontaneously, the mother drops in something about how her daughter is an artist who spends all her time in her room drawing. Now the mother's giving this to us as a bit of a complaint to show how antisocial her daughter is, or how - you know, she has this concern that her daughter doesn't like to relate to anyone. It would have been actually really good for you to pause at that point and say, do you have any drawings I could look at. You know, when you take an interest like that, it - it's - you're modeling for the parent, that that's important for us to pay attention to. And yes, there's a concern about being social and it's not that we're going to ignore the problem but you can take a moment - it would take 3 minutes to simply look at some drawings and say wow, she really does have talent there. >> That's a great example and then, knowing what you can do with that information after the fact. There's so many things that you can do with knowing oh, she's really - it's a talent of hers, it's an interest of hers, and how that talent and interest can help her maybe, maybe help her with develop some skills around trying to emotionally regulate herself. It could even help her develop some skills around how to interact with other youth. You never know, there could be even like an art club, or an art program in school that she's interested in that. That might be jump off point to help her socialize with others. It reminds me of a situation we had a youth that was transitioning out of residential care home and back to his community school. And he was very bright but really struggled socially as well. And his mother often complained similar to your situation about he spent all his time watching TV, and he was so into movies and drama, but then come to find out, this was a real strength and interest for him. And the clinician that was working with him did a great job getting him connected to the drama program at school. And then within six months, we checked back and find out that he's participating in the drama club, he's made all these new friends as - you know, that he connected with. And it was just from that conversation of what is he interested in and what does he like to do and then using that to connect him and to work on his social. It's - you know, it's really looking at how a strength can be functional, how it can help youth and how it can help them function in other areas.

Hope, Motivation, and Confidence in Families Voiceover transcript: Finally, Anthony and Beth discuss how focusing on strengths builds hope, motivation, and confidence in families.

Video: The Values of Strengths Video transcript: >> I think teams will move in a direction where they see value, and I think that's our challenge, is that, again, we've trained staff, most of us. I certainly was part of my training, a lot more emphasis was placed

on being able to ferret out the problem. And that's what was valued, and that's what the definition of a good clinician was the ability to do that. And so, I think part of the transition we're in right now is demonstrating the value to people of why it's important to talk about strengths. And I think, you know, we have a lot of the data from the world in motivation enhancement, right, to know that helping people change is, in part, about helping to build their motivation to change. And we know that if families can rediscover for themselves, strengths, and feel good about strengths, their motivation and confidence increase. So, we have to demonstrate to staff that they're doing something very powerful, that having a conversation about strengths is a very powerful intervention. It's a very sophisticated intervention, it's not superficial. It's not simply being optimistic. And I think if staff can understand that this is very powerful work, I think they'll tend to spend more time on it. And I think it's up to us, as supervisors and trainers, to make that case. >> I have to say one of the best care plan meetings that I have ever observed is where the care coordinator started off saying - and started talking about strengths but not in a way of oh, so, let's talk about strengths and tell me what, you know, so and so's strengths are, but started the conversation around, let's talk about some areas that are going really well, or some progress that we've seen. And that really took this - the whole group worked together and everybody was adding a piece about - even baby steps of progress. And it was such a great thing to see because I see - I'm watching the caregiver's face and you can see the hope is restoring. And then the youth is feeling like wow, they're really paying attention to me and this isn't going to be one of those meetings when they tell me all the bad things that I'm doing. It really set the tone for the whole entire meeting and even when it came time came to talk about the concerns, they were able to do that in a way that was easier for the youth to hear because they had just talked about this progress. And it was just - it was a great process to observe and it really showed the importance of everyone working together as a team in the strength based plan. >> And one of the best ways in a care planning meeting to help the group really buy in is to help the group understand where it's being successful. Nobody wants to feel like they go to their work and they're being unsuccessful. And so, when you come together around a family to do planning, if we're not paying attention to progress, if we're not paying attention to the ways and what strengths are sort of growing, then we're really missing an opportunity to build hopefulness and to build motivation and to build confidence in people.

CBHI Values: Culturally Responsive Voiceover transcript: For CBHI services to be responsive to the family, they also must consider the family’s cultural context. Significant racial, ethnic, cultural, and life experience disparities exist in people’s access to and engagement in behavioral health services. Culturally responsive practices can help address these disparities.

Culturally Responsive Practices Voiceover transcript: After reading this slide, listen to some of the different viewpoints about culture that we have heard expressed around the state. First, Dalene Basden discusses culture as her community with Bonny Saulnier.

Video: Bonny Saulnier Discusses Culture with Dalene Basden Video transcript:

>> Race sometimes is -- you know, or cultural considerations about race are some of the big topics, but there's also culture of your specific family's culture. Were those specific conversations about culture helpful in allowing the clinical team to understand your particular family, the ways that you operate, your beliefs and values? >> Well, one of the things that's important to me and you may have heard me state is that culturally comfortable for me and my culture is my community. So in the long run it does help because the questions about culture did get to the root of where I come from and I come from my community. I've lived there for so long, I depend on my community for support. So eventually the questions about culture did get around to that piece of it -- what is my culture? And for me, my culture is my community. And when the provider understands that, and knows my community, it knows what's available for me in my community, in the long run it does help and it gets me culturally comfortable.

Queer and Trans Identities Voiceover transcript: Then, Joel Coburn and Hannah Karpman examine the role of curiosity for a queer clinician working with queer families and others who might identify under that umbrella.

Video: Curiosity About Culture Video transcript: >> So I know you work in an area where there is a lot of queer families in the variety of ways that people might identify under that umbrella and so I'm wondering if you can talk about what does it mean to be culturally responsive when you walk in to a family that might look different than the heteronormative families we think about. >> Yeah, I mean, I think that that's a really incredible part of this area is that there are people who are thinking about that and I think, I mean, I go in and just try to be curious. You know, I think that as a queer clinician sometimes I can think like oh great, like I kind of-- I know about you, right, like there's some similarity that I can assume that may not be the case. I think one thing that is really important is that for building a relationship, and especially because queerness and kind of trans identities are marginalized is that I think a lot of families do experience an excitement and a relief around meeting someone who is legible as maybe part of a larger community for them; I hear that a lot from people, that wow like I didn't know that there were queer clinicians, you know, I didn't know that. Like that's awesome, how come we didn't have one before, you know. And so it is a trap sometimes to be like yeah we're the same, so I still kind of have to have the same curiosity around what their experience is, who they are. I think one way that I feel is important to be culturally competent or responsive is really to give a lot of space for language and identity. So great, how do you-- how do you have a relationship as caregivers? You know, I don't want to assume are you married, you know, or are you just partners, right. So what-- what words do you use to kind of describe yourself as caregivers, you know. You let me know, like what words does the kid use to call you and that way I can kind of know what I'm going to use when we're talking. So you and your partner and someone might say no like me and my wife, you know, or whatever, but I don't want to make those assumptions.

Further Discussion About Curiosity and Cultural Responsiveness Voiceover transcript: Hannah continues to address curiosity with Sarah Belding who gives us some excellent examples of family situations that might be overlooked if clinicians are not curious.

Video: Curiosity and Understanding Alternative Families Video transcript: >> So Sarah, we were talking with Joel a little bit about this earlier. I know you work in an area that has a pretty well represented population of queer families and also families and kids who might have different gender identities or different gender expressions. And I'm wondering sort of in that environment, what do you think makes a culturally responsive service? >> Just like with any population, I think that it's important to ask a lot of questions and to be curious and to not make assumptions. So not making assumptions about how a family might identify or how a family might even be constructed. You know? Not make assumptions that there are two caregivers or that there might -- a lot of our -- a lot of families in the area particular lesbian identified families use known donors. And those known donors are sometimes really involved in the family. And so there's kind of like a surrogate third parent that's part of the family. And they'd be important to include in services as well.

Some Implications of Race and Culture Voiceover transcript: And, although you might have viewed the following video in the introduction, you might want to listen again to Celia Hilson talk with Maria Torres about a situation that really made her think differently about the clinical implications of race and culture.

Video: Prompting a Discussion of Culture Video transcript: >> In an earlier conversation today, we were talking about what it means to be coming into someone's home, and how exposing, how vulnerable that can be for a family. So, when we layer on top of that how we think about culture, and how fearful people may be with someone coming into your home, because you are so exposed, I'd love to hear, you know, how you, when you first meet a family, how do you engage them? How do you start that relationship, and then how does culture play a role? >> I'm a little more conscious of walking into homes of white families, because I may have the assumption that they don't expect to see someone like me, and that assumption is sometimes challenged. Like, yes, that might be true. And then, there's a black family who may also not expect to see me. So, I just recently, after working with this family for, since September, they opened up a discussion about how they didn't expect to see me coming through the door, that they were shocked, A, that I was black, B, that they didn't expect a black clinician, nor did they want a black clinician. >> And, this was a black family, or a white? >> This was a black family. And, so I thought, "Oh, this is interesting. Tell me more." And so, they just started unpacking all of these assumptions and perceptions, and I thought, "Wow. First of all, it's really courageous to even name that," and to me, it spoke to the nature of the work that we were doing, that they felt comfortable enough, and trusting enough, to even name that, down to physical appearance. And so, I felt like it was a great opportunity to look at oppression on different levels. So, here's the presentation of internalized oppression with this family. Like, even though you look like me in some ways, you're not what I expected. And, I didn't expect that you could be competent in this role. So, here's this unspoken fear, this whole time. I was shocked, but I didn't register that. I welcomed it as a opportunity to say, "What does this mean for you?" And then, asking myself, "What does that mean for

me?" So, I just named it right there. I said, you know, "So, you had this perception that I would be a white clinician, and somehow that would be, fill in the blank, better. Oh! Let's talk about that." So, it was really great to just kind of deconstruct all this stuff, and then at the end of that conversation it was, and what we've learned is that that's not true, and what we've hoped for showed up in this context. Now, all these things we believed about therapy is not necessarily true. So, moments like that sort of remind me of why I do this work. So, that's one, I think, great example of how culture and race and identity plays into this.

Disparities in Access to Care Voiceover transcript: Regardless of how reactions to culture are individualized, the responsive professional recognizes that disparities in behavioral health care are well documented. Such disparities are the result of many factors, such as one’s native language, access to transportation, ability to pay, or access to insurance.

CBHI increases cultural responsiveness by trying to address these issues in their program requirements—

such as requiring that services be provided in homes and in the community. Also, CBHI contracts with specific providers who focus on under-represented communities. Gandara specializes in Latino and Spanish-speaking communities in Boston, Worcester, and Springfield; Children’s Services of Roxbury helps provide services to African-Americans in greater Boston; and Walden School offers services to families with children who are deaf or have family members who are deaf. Finally, CBHI also addresses these issues by prompting clinicians to engage in culturally responsive practice and conversations through the use of the cultural considerations domain in the CANS.

CBHI Values: Collaborative and Integrated Voiceover transcript: Another CBHI value is that services are collaborative and integrated. As noted earlier, it is challenging for families to work with multiple providers and multiple systems. CBHI aims to have these providers work together, so that youth and their families have an integrated plan, with all stakeholders working together with the family toward the same goals. Collaborative, integrated care eliminates conflicting advice and duplication of effort. In the next video, Bonny Saulnier and Jack Simons talk about how collaboration and integration comes from the various providers working with the same child when they are all using CANS.

Video: Integration and Collaboration Video transcript: >> Jack, you know that the CANS is required for a lot of different levels of care, and types of care, and in different intensities of care? So, for example, a young person might be in a community-based acute treatment program and after two weeks of 24 hours a day care, have a CANS done by the team. On the other hand, a child in outpatient therapy might only see the clinician once in that same two week period. So, what are your thoughts about how to integrate the different information that you might get under different service types? >> You know, that's a really good question. I think it goes back, in a way, to whenever you're working collaboratively, you have to be thinking about who's producing this information? What's the basis of their knowledge. So, you never assume that everything you get from another provider is 100% accurate. We all have limitations in terms of what we know. And if you think about who the providers are, there's going to be some systematic differences. So, like you say, a 24 hour level of care is going to know a lot about how that kid has behaved while they were on the inpatient unit. They're not going to know much

about the history. They may not know much about the family even because they've had a narrow window to gather that information, and that's fine. What I want to know as an outpatient provider, or IHT, or some other level, after a kid has been in a CBAT or an inpatient level is what happened there? What did you learn in that special situation that will inform my work as an aftercare provider? So, it's okay that you don't know everything, I want to know what do you know. And one of the great things about having those text fields in the CANS is it provides an opportunity for us to say, here's the basis for my information. Or I really didn't get a chance to learn about these particular areas. Or I think this domain might be an area that deserves more exploration and I suggest that that should be part of what other people do subsequent to, you know, us working with the family.

CBHI Values: Continuously Improving Voiceover transcript: Finally, CBHI recognizes that, in order to achieve high-quality services, it is critically important to adopt continuous improvement as a value. Successful large-scale systems change requires that everyone involved be willing to examine their role, and look for ways to improve in their areas of responsibility. In the next video, Deborah McDonagh and John Lyons discuss the changes in the CANS training as a good example of what we mean by a culture of continuous improvement.

Video: Deborah McDonagh and John Lyons Discuss Improvement Video transcript: >> Massachusetts started using the CANS in 2008, I hear you've got some big changes planned. What are you doing and why now? >> When we started using the CANS training program in 2008, CANS was not a commonly-used tool in Massachusetts. We had to train a lot of providers in a very short period of time, so our focus was on CANS basics. We were teaching providers about CANS characteristics and principles so they could use it as part of the behavioral health assessment. Through years of provider feedback and a comprehensive evaluation of the program, we learned that providers wanted to know more. They wanted to know how to use it in daily practice. That means that they wanted to know how it helps to support family engagement and how it informs treatment planning, as well as how it fits within the CBHI menu of services, and more about their roles as Hub service providers. We learned that, from a training perspective, that people need an even greater emphasis on understanding cultural considerations, and also that we have to provide additional support and guidance to providers in outpatient settings. At this time, we now know that we have the provider input, we have the added knowledge, and we have the resources to create a much more dynamic training program that fits within the CBHI model of care. So that supports CANS as part of the family-driven, collaborative community-based quality model of care. >> That's outstanding! I think that's the process of change, right? >> Absolutely! Absolutely. And it has been a process of change for our providers, but also for us as a training program.

Interactive Exercise 3

Interactive Exercise 4

Hub Services

Voiceover transcript: Let’s turn now to the System of Care developed by CBHI to help families get the right level of service for their child. All CBHI services have been organized around three clinical Hubs: Intensive Care Coordination, In-Home Therapy, and Outpatient Therapy.

Hub Provider Responsibilities Voiceover transcript: Hub providers are responsible for the activities listed on this slide, for example, communication and collaboration with other providers, and, in partnership with the family, overall coordination of the care among the various providers. Youth and families may receive one, two, or all three Hub services at the same time—depending on the need and preferences of the youth and/or family.

Care Coordination Voiceover transcript: This slide illustrates the relationship between different elements of the CBHI system. Starting at the large diamond on the left, families independently, or in consultation with helping professionals, make a decision to seek services. Initially, these might be emergency services, Intensive Care Coordination, In-Home Therapy, or Outpatient Therapy. The box on the right shows what are called “Hub-dependent” services. They are called “Hub-dependent” because youth and families can only access these services if their Hub provider refers them for the service. The Hub provider’s treatment or care plan describes how the Hub-dependent service is meant to be helpful. We will review these services in more detail later, but as indicated in the bottom box, a child may receive more than one Hub service at the same time. When more than one Hub service is working with a family, the care coordination responsibilities belong to the most intensive service. As the chart indicates, Intensive Care Coordination is the most intensive Hub coordinating service, In-Home Therapy is the next most intensive, and Outpatient Therapy is the least intensive Hub coordination service. Thus, if a youth is receiving all three of these Hub services, the Intensive Care Coordination provider would be responsible for care coordination. If a youth is engaged with In-Home Therapy and Outpatient Therapy, then the In- Home Therapy team provides care coordination. Finally, if the youth is receiving Outpatient Therapy only, then the Outpatient therapist is responsible for the care coordination. Let’s examine CBHI services in more detail, but remember you are responsible for following the Medical Necessity Criteria, Performance Specifications, and Service Definitions published by CBHI. See the Resources listed earlier.

Intensive Care Coordination (ICC) Voiceover transcript: Intensive Care Coordination, or ICC, is an intensive, individualized care planning process for youth and their families. ICC is provided by Community Service Agencies (or CSAs). Using the Wraparound process, a facilitator, called a care coordinator, works with a family to convene a Care Planning Team whose purpose is to understand the youth and family’s strengths and needs and to create and implement an Individual Care Plan with the youth and family. Care Planning Teams often include therapists, school administration and/or support staff, and social workers. Care Planning Teams also include “natural supports” such as family members, friends, and people from the family’s neighborhood or community.

In partnership with this team, the family actively guides the youth’s care. Together they help identify

goals, come up with ways to help the family and youth achieve those goals, and monitor whether the care plan is working. The Individual Care Plan helps to get everyone “on the same page”, thus ensuring that the services are integrated and coordinated.

Who is likely to benefit from Intensive Care Coordination? Voiceover transcript: One question families and helping professionals should be asking is, “What is the best level of care for the youth?” When considering ICC, think about the level of coordination that is needed. Families who are raising a youth whose mental health needs are complex enough to require services from multiple providers should strongly consider Intensive Care Coordination. An example of a youth and family who would likely benefit from ICC is described on the next slide. Please read Abdi’s story.

Who is likely to benefit from Intensive Care Coordination? Voiceover transcript: Intensive Care Coordination would be the appropriate Hub for Abdi and his family. ICC could help the family prioritize their needs, build consensus among DCF, the shelter, the school, and the family to get everyone on the same page, and assist in accessing appropriate behavioral health care for Abdi. Moving forward, the ICC Hub would help coordinate these services, support the family in connecting with community resources for basic needs and community engagement, and track whether all these efforts are resulting in improvement.

In-Home Therapy (IHT) Voiceover transcript: In-Home Therapy, or IHT, is a flexible, strengths-based service that allows providers to deliver intensive family therapy and care coordination to the youth in the home, school, or other community settings. A clinician and trained paraprofessional work with the family to understand their strengths, cultures, values, and needs in order to develop and implement a treatment plan that improves the youth’s and family’s functioning. IHT providers might help resolve family conflict, strengthen communication, engage natural supports and community resources, and address safety in the home. IHT offers greater flexibility than Outpatient Therapy, not only in intensity, but also in treatment setting. Therapeutic work in a natural environment offers opportunities for rehearsing new strategies that are not available in an office setting. IHT builds the family’s capacity to prevent or reduce admissions to an inpatient hospital or other treatment setting outside the youth’s home and community.

Who is likely to benefit from In-Home Therapy? Voiceover transcript: Like the question asked of ICC, you should be thinking about who is likely to benefit from In- Home Therapy. This slide lists what you should consider. For example, families whose home dynamics are negatively affected by a youth’s behavioral health needs and who want to improve their family’s functioning. In the next slide, read two examples of children and families who could benefit from In-Home Therapy.

Who is likely to benefit from In-Home Therapy? Voiceover transcript: Both families would likely benefit from some coordination of care, interventions that involve the whole family, opportunities to practice in real-time settings, and development of community resources.

Outpatient Therapy Voiceover transcript: Outpatient Therapy meets the needs of many who need mental health treatment. Moreover, it is usually the place that families go first when they need help, and where youth return after receiving higher levels

of care. Outpatient Therapy can be helpful for a variety of behavioral health, developmental, and/or substance abuse issues that significantly interfere with functioning in at least one area of the youth’s life (such as family, social, school, job). Outpatient Therapy is usually delivered in a clinician’s office, although it might take place in other settings. Of the three Hub services, Outpatient Therapy provides the least intensive level of care coordination.

Who is likely to benefit from Outpatient Therapy? Voiceover transcript: Who is likely to benefit from Outpatient Therapy? If the child or youth has not previously received counseling or other behavioral health services, or has benefited from Outpatient Therapy before, Outpatient Therapy is a good place to start. An outpatient therapist can provide an initial assessment and discuss with the family the possible need for other services. Outpatient Therapy can also provide follow-up support for children and youth who are “stepping down” from more intensive services or settings. Many children and families will benefit from Outpatient Therapy. Here are some examples:

Who is likely to benefit from Outpatient Therapy? Voiceover transcript: Examine the three examples on this page as children and families who might benefit from Outpatient Therapy.

Differences between In-Home Therapy (IHT) & Traditional Outpatient Services Voiceover transcript: Further comparisons between In-Home Therapy and Outpatient Services might be helpful. In-Home Therapy offers more intensive treatment and care coordination, and often more flexibility with scheduling. Typically, there will be more visits per week and those visits will be of a longer duration. However, for some families, such intensity may be too much, and the level of care coordination needed is minimal.

Determination of Hub Service Voiceover transcript: The determination of Hub services is based not only on the assessment by the clinician, but also on input from the youth and family regarding their preferences. In the case of an ICC team developing a care plan, for example, it is important to explain the benefits of each service to the youth and family, so they can make an informed choice. Hub services can change depending on the changing needs of the youth and family. Remember that youth and families may receive one, two, or all three Hub services at the same time, depending on their needs.

Hub-Dependent Services Voiceover transcript: Once the child is enrolled in a Hub service, it might be determined that additional services would be helpful in assisting the youth and family to achieve the goals in their treatment or care plan. Among these additional services are those referred to as “Hub-dependent services.” They are Hub-dependent because referrals are made by the Hub provider, and the Hub- dependent services cannot continue without active involvement in a Hub service. Hub- dependent services assist with goals in a treatment or care plan developed through the clinical Hub provider. As with all services, the youth must meet Medical Necessity Criteria in order to enroll in these services.

Therapeutic Mentoring Voiceover transcript: Therapeutic Mentoring is a Hub-dependent service that pairs a youth with an adult mentor for the purpose of enhancing a youth’s social, communication, and life skills. The Therapeutic Mentor works one-on-one with the youth to achieve goals in the Outpatient or In-Home Therapy treatment plan, or their Intensive Care Coordination care plan. Therapeutic Mentoring services can be delivered in the home or other community-based settings, such as recreational centers, parks, and clubs.

In-Home Behavioral Services Voiceover transcript: In-Home Behavioral Services is a Hub-dependent service that supports youth who have challenging behaviors that interfere with everyday life. This service, provided by a behavior management clinician and a trained paraprofessional, includes a functional behavioral assessment, development of a highly specific behavior plan, supervision and coordination of interventions, and training caregivers to address specific behavioral objectives. The behavior management therapist works closely with the family to develop a specific behavioral plan and interventions that are designed to diminish, extinguish, replace, or improve specific behaviors related to the youth’s behavioral health condition(s). The paraprofessional, also known as a “monitor,” works with the child and family to reinforce implementation of the behavior plan by the parent/guardian/caregiver, and reports to the behavior management therapist on progress toward behavioral objectives. In-Home Behavioral Services can be provided in the home and other locations, such as school, child care, and other community settings. This service may be most appropriate when less intensive behavioral interventions have not been successful. It may also be appropriate when a clinical evaluation suggests that the youth’s clinical condition, level of functioning, and intensity of need require the establishment of a specific structure and consistent application of positive behavioral supports across home and school settings.

Family Support & Training (Family Partners) Voiceover transcript: Family Support and Training is a Hub-dependent service that provides a structured, one-to-one, strengths-based relationship between a Family Partner and a parent/caregiver. Family Partners are caregivers themselves, who are raising or have raised youth with behavioral health needs. Family Partners also have experience working with child-serving systems and a variety of professionals since they have worked to support their own youth in these systems. As a result of this direct life experience, Family Partners are able to provide unique emotional support for the caregiver, foster empowerment, and encourage the expression of family voice. Family Partners often share parts of their own stories with the intention of helping caregivers develop insight and the motivation to act on their youth’s and family’s behalf. Family Partners work under the supervision of a licensed clinician and goals established in an existing treatment or care plan from one of the clinical Hub providers.

Common Characteristics of All CBHI Services Voiceover transcript: All CBHI Services adhere to the following values, which we discussed earlier. They are: Child Centered and Family Driven, Strengths Based, Culturally Responsive, Collaborative and Integrated, Continuously Improving. In addition, the Rosie D. settlement in 2006 required that all CBHI services use the CANS as a common assessment tool. Let’s listen to Emily Sherwood, who led the Children’s Behavioral Health Initiative through its first decade, describe some of these values using CANS as her example:

Video: Emily Sherwood Discusses CBHI Values Video transcript: >> Well, I think the thing that excites me about the CANS is we're able to use a tool that has in it, that's embedded in it, are the values of the system of care values, or you could call them the CBHI values. And I'll just kind of summarize it in this way; so first of all, it understands kids in their ecological context. Kids thrive or struggle in their family, with their peers, in their school, in their community. And the CANS reflects that broad look at a child's psychology. It also reflects the fact that we know if we're going to really help kids and families achieve their goals for their kids, we have to pay as much attention to what their strengths and resources are as we pay to their struggles and their problems, and that's reflected in the CANS. So - and then, you know, we can have - or, you know, clinicians can have a great plan that they think will help a child and their family. If it doesn't make sense to that child and family, if it doesn't speak to their goals, to the things that are going to motivate them to do the hard work, it's not going to work. So, the CANS is a tool for having those real grounded conversations. What's really going on? What are the worries? What are the strengths? What's most important to attend to first? So, it sets that foundation. And then we also know kids live in a world of a lot of different adults, so they've got their families, they're in school, they have a pediatrician. There may be other service providers and all of those people have to be pulling in the same direction, in alignment with the child and the family to reach those goals, and the CANS helps to do that.

Interactive Exercises 5-12

A Common Language is Needed in a System of Care Voiceover transcript: Another important concept to consider about CBHI and what it’s trying to achieve is the idea of having the common language to address treatment and care. The CANS can be an effective way to help a wide range of helping professionals develop a common language around the work they are doing with a youth and family. The video clip that follows gives an overview of why a common language is important to a system of care.

Video: Discussing the Benefits of a Common Language Video transcript: >> We're using the CANS assessment as a tool across all services. Why is that important? >> Across Massachusetts, many different people do behavioral health assessments, a very diverse group, and using a variety of tools, and yet a system of care relies on really good collaboration and integration of information and planning. So, having a common language, that is the CANS, to pull together all of the different information is essential to a system of care. The CANS also is used by some of the state agencies, the Department of Children and Families, the Department of Mental Health, and others, so they also are included in that common language in the system of care. And, it's valuable for families, as well, because it's a common language that can be shared with families. CANS creates an inclusive process that involves everybody that needs to be part of a child's care.

A Common Language for a Range of Stakeholders Voiceover transcript: Note that a system of care depends on communication among a range of stakeholders with different backgrounds, perspectives, and languages. “Language” here refers to the literal differences, such as the jargon used in different disciplines, and concepts that don’t translate precisely from one’s language to

another’s. It also refers to more abstract differences, such as concepts that require specific academic knowledge to be understood, or words with connotations that are open to interpretation. For example, understanding a term like “flat affect” or “dyskinesia” would require specialized knowledge. Words like “appropriate” and “risk” are common words that are open to many definitions. CANS, which defines each item in clear and simple language, is a process that promotes understanding across different helping professionals.

For Family Voice and Choice… Voiceover transcript: For many families, assessment language can be full of abbreviations and other jargon. This may feel intimidating, disrespectful, or marginalizing-- none of which support a family-driven approach to care. Also, some assessment tools may address a family’s situation in ways that don’t feel relevant to the family’s daily experience – for example, if the assessment focuses on the far distant past, if the questions are all about problems without accounting for strengths, or if only one viewpoint is taken into consideration. This process can feel professional-driven rather than family-driven. And finally, when families need to complete different assessments for different providers, they may get weary of repeating their story. At the same time, they may be reluctant to expose private information about themselves. A common language helps families have real voice and choice in a system of care. In the following video, Medgyne Lubin describes the explanation she gives families about how sharing information electronically across providers helps them.

Video: Consent and Common Language Video transcript: >> Working with families that sometimes have because of their culture or their history or previous experience with the system, are very hesitant to sign any consent forms or to fill out paperwork that may be associated with the CANS or really any other thing that may be happening in their lives. Can you talk to me about, you know, if that's something that you've encountered? And if so, how do you navigate that when you're trying to work with a family? >> So I've often had families say I'm not going to sign the consent. I don't want my personal information, my child's information, their diagnoses, all the help that we need or needs, I don't want that information on the computer database that, you know, everyone can see. So at that point, definitely validating the family's feelings about that and understanding their culture and what that means to have their information put on a database but then also reminding them that it just means that it -- like you said, going to be communicated from provider to provider. So the next CBAT, the next inpatient, when the IHT or CBHI provider's put in place, you don't have to repeat yourself and tell everyone the same story or you know, the same strengths but that everybody will already have that information I think has been the greatest window to getting them to start to explore and understand the meaning of CANS and then approve of having that assessment completed.

For Clinicians… Voiceover transcript: We have talked already about the benefits of using a common language for clinicians. Once it’s mastered, CANS can be far more efficient for integrating different assessments for different service types than having each provider agency choose its own form. A common language assists clinicians in completing assessments efficiently so they can start treatment in ways that are responsive to families’ immediate needs. Sharing CANS across providers (with family permission) can assist with the

communication without needing to crosswalk from one set of items or narratives to another. In this way, CANS supports CBHI’s value of Collaborative and Integrated care among treatment providers.

For State Agencies, Schools, and Other Helpers… Voiceover transcript: Collaborative and integrated care extends beyond treatment providers to include state agencies, schools, and community supports. The clear, common language of the CANS helps across disciplines and areas of expertise. Similarly, a common language can be used with extended family and other natural supports, whether they have professional expertise or not.

For Quality Improvement… Voiceover transcript: Finally, a common language has the advantage of creating a platform for constructive comparisons of outcomes across diagnoses, clinicians, programs, and systems. At all levels, practice strengths can be highlighted and system gaps, training needs, or other areas for improvement can emerge.

Interactive Exercise 13

Interactive Exercise 14

Case Conceptualization Voiceover transcript: Now that we have discussed how CANS helps us develop a common language for the gathering and sharing of information, let us turn our attention to the next important aspect of our work— how to understand what all of this information is telling us. Before we can put in place effective interventions and services, we need to have some kind of understanding as to what is going on. We will refer to the process of understanding as “Case Conceptualization.” Gathering information is just the beginning. But what does this information tell us? How can we make sense of it? For example, when presented with the picture on the left, one might not recognize it. But by asking questions about the information we have gathered we can begin to fill in the blanks, and a more recognizable picture can emerge—like the one on the right. Once we understand what we are seeing, we can begin to interact with the picture in ways that makes sense. There are different ways to describe case conceptualization, but we think of a case conceptualization as a process of mutual discovery that unfolds over time. A process where the clinician brings their learning, training, and experience into dialogue with the family to begin to understand what is happening, why the youth and family are experiencing what has been observed, and what might be the optimally effective therapeutic interventions.

Family Driven and Culturally Responsive Case Conceptualization Voiceover transcript: Traditional models of case conceptualization tend to put the responsibility for understanding solely with the clinician, leaving the family with the role of simply providing the data. However, as we have seen, if our practice is to be truly family driven and culturally responsive, then we must work to understand the information we gather from the family’s unique point of view. Their point of view is shaped by their specific cultural context and their lived experience. This graphic illustrates the process. Our understanding begins with gathered information. As we have seen, the CANS is an effective tool for efficiently gathering and organizing a large amount of information about the strengths and needs of the youth and family. However, good case conceptualization requires that we then understand the meaning

of this information. It is a conversation where the clinician uses his or her learning, training, and experience to help families better understand their situation and develop hypotheses about why things are the way they are. However, it is also a conversation during which youth and families teach us about their unique perspectives on these issues—a perspective and understanding that is heavily shaped by their culture and values. It is through this process of mutual understanding that good case conceptualization can be developed. Of course, at the beginning, the clinician and family might arrive at one set of ideas, but over time, as information is gathered, and as interventions are tried, our conceptualization should change, deepen, and become more accurate. In other words, good case conceptualization is not simply something that happens at the beginning of our work with families, but should be an ongoing process of understanding that unfolds over our entire time with them.

Youth and Family Information Voiceover transcript: Let’s take a look at this process in more detail. The information that you have about the family and youth may come from a variety of sources. This includes your conversations and assessment with the youth and family, information you have in writing or from conversations with other providers, or information provided to you by other important people in the youth and family’s lives. Previously completed CANS can also be an important source of information. One of the benefits of CANS is that it helps you organize your youth and family information to see emerging themes.

Scientific Literature Voiceover transcript: Each clinician will have exposure to different theories based on their training. The scientific literature can help inform our conversations with youth and families. The scientific literature helps us begin to think about the family’s situation, and can give us clues as to how to develop hypotheses about what is happening and how best to help.

Clinical Training and Experience Voiceover transcript: Our clinical training and experience also play an important role in helping us understand the information we are gathering. This experience and training, sometimes called “practice wisdom,” can help us make sense of what we are seeing and learning through our work with the family. For example, you may have a particular expertise within a community or geographic area, which will give you an advantage when working in those contexts.

Interactive Exercise 15

Interactive Exercise 16

Family Culture and Lived Experience Voiceover transcript: It is important to remember however, that no matter how good our training or experience is, or how knowledgeable we are of the literature, if we do not take the time to understand the family’s specific cultural context and point of view, our case conceptualization will be flawed. A family’s values and culture play a central role in how they understand their child, their child’s behavior, and the needs of their family as a whole. The family’s cultures and experience of themselves will also influence how open they will be to your ideas about what is happening and what might be recommended interventions. This

is why it so important that you approach the process of case conceptualization as a process of mutual understanding between you and the family. Understanding cultural responsiveness is one of the most complex skill sets to learn; we refer you back to earlier training where cultural responsiveness is discussed as a core value for CBHI. We will also return to questions of culture when we explore the role of CANS in everyday practice. For now, we leave this important topic with the following video. Here Hannah Karpman asks Joel Coburn, an In-Home Therapy clinician, how cultural context plays a role in understanding the families with whom he works and how he uses and thinks about culture in his assessment process.

Video: Being Thoughtful about Cultural Identities Video transcript: >> So, one of the things I know about you is that you're very thoughtful in your clinical practice about your own social and cultural identities when you interact with clients. So, can you talk to me a little bit about that, or give me a case example where you sort of thought that through? >> With any case, I'm thinking about identity and what the relationship is going to be like, you know, because for my work, that's the crux of it, because we're going to be collaborating, and we need to build a relationship. And, each relationship is going to be different and informed by who you are in the world, who I am in the world, and how we come together and see each other, or don't. I think a recent case example that is on my mind a lot lately, I'm a white male-presenting person, and I have enormous privilege around that, and that that's always going to be one of the first things that somebody notices about me, and is going to inform how I see things, and how I interpret them. >> So, when you say you're conscious that that gives you enormous privilege, what does that mean, like, in the day-to-day sense, what does that mean? >> I mean, I don't experience racism, right? Like, on an institutional level, on an interpersonal level, that's not part of my experience. It's part of my training, and conversations that I have, as somebody who's kind of committed to social justice and anti-oppression work, those are conversations that I have, but I don't experience those. You know, I can go into a place and see people who look like me. I can go into a place, and have, I'm part of the dominant group, and the kind of sociocultural power that comes along with that. >> And so, how do you bring that up in a therapeutic relationship? How do you broach that topic? How do you acknowledge that privilege? >> I mean, thinking about a woman that I've been working with for a number of months, now. When we first met, you know, she's a woman, she is Latina, and she had recently expected horrific intimate partner violence from a man. And, when we met, that was, you know, that was so acute for her, that trauma, and it was rooted in her experience as a person who is oppressed by white people, oppressed by men. And, I went into that work with her knowing that I was going to show up at her door, because I had some context of why she was seeking treatment with her family, and I go to her door knowing that I'm going to have to negotiate that, of course, and that she might be afraid of me, and that I need to know that, and respect that.

Family Driven and Culturally Responsive Case Conceptualization Voiceover transcript:

Let’s review: The process of good case conceptualization begins with the gathering of youth and family information. The CANS is a tool that helps to efficiently gather and organize that information. This information then needs to be discussed with the youth and family in a way in which mutual understanding of the problems and possible solutions are developed. Your expertise in this conversation involves your knowledge of the scientific literature and your clinical training and experience. The family’s expertise involves their culture and values, their lived experience and how they view the challenges with which they are living. It is through the skillful combining of these different types of expertise, through respectful dialogue, that a good case conceptualization can be collaboratively developed. Having arrived at a conceptualization of the case, you and the family are now in a position to develop interventions to help improve the situation. Let’s listen here as Hannah Karpman summarizes the importance of family and youth expertise and ongoing learning, as she walks through how she thinks about case conceptualization.

Video: Clients and Families as Experts Video transcript: >> I think it's really easy for us to think as the formal providers we're the expert. We know how to treat this problem or we know -- our evidence based practice tells us to do x. And it's important to recognize that families and people and sometimes even children especially are their own experts. And that we have to learn from them and they can -- in a continuous way. And there are things that even five or 10 years ago, we might have approached as a strange cultural practice that are now our mainstream treatment. Yoga. Mindfulness. Acupuncture. And all of those things make me realize increasingly how important it is that we realize we're always learners and our clients and our families are the teachers. And that we keep an open enough mind to understand that what works for us or even maybe what we've been taught will work might not work for our clients or our families or our kids and that we're listening enough to them to hear what they think works. And what maybe wisdom in their community tells them works.

End of Module