Provider Capacity to Address Key Child Welfare Outcomes among Parents with Behavioral Health Issues by fsuchildwelfare

RESEARCH REPORT

Behavioral Health Provider Capacity to Address Key Child Welfare Outcomes among Parents with Behavioral Health Issues April 12, 2019 Heather A. Flynn, Ph.D. Shamra Boel-Studt, Ph.D. Patricia Babcock, Ph.D. Heather Venclauskas, MPA Carolin Hoeflich, BS Yuxia Wang, MPH

CONTENTS Abstract..........................................................................................................................................1 Background....................................................................................................................................2 Project Description.........................................................................................................................2 Qualitative Study............................................................................................................................2 Analysis......................................................................................................................................2 Results.......................................................................................................................................3

Funded through a contract with the Florida Institute for Child Welfare

Training Development and Results................................................................................................7 Quantitative Study..........................................................................................................................8 Analysis......................................................................................................................................8 Results.......................................................................................................................................8 Discussion and Implications for Recommendations.....................................................................10 Preliminary Recommendations to Consider Based on the Qualitative Findings..........................11 Preliminary Recommendations Based on the Quantitative Findings to Consider for Training and System Changes for Behavioral Health Providers.......................................................................11 Specific Behavioral Health Issues and Training Implications for Behavioral Health Providers....12

Abstract The overall goal of this project was to determine the capacity of behavioral health providers contracting with Big Bend Managing Entity (Judicial Circuits 2 and 14) to effectively address behavioral health issues among parents involved in the child welfare system. In addition, a goal was to determine the training and system-level needs required to improve the ability of behavioral health providers to effectively address these issues. The project investigated specific parental behaviors that directly affect child well-being, safety, permanency and risk of future child abuse and neglect. A mixed-method, longitudinal approach was used to achieve the project goals. Primary behavioral health providers in the circuits who receive referrals from child welfare agencies were identified and engaged in the project. Both qualitative and quantitative data were collected. Quantitative data included extracted information related to caregiver behavioral and emotional capacities as assessed and recorded in child welfare case records (N = 212). Data from behavioral health staff included information on perception of roles and responsibilities; detailed information on training, knowledge and skills required to address specific parental behaviors that directly affect child safety, well-being and permanency; and training needs. The behavioral health provider data were evaluated against the Caregiver Protective Capacity Form. Data from the child welfare side included information on effective completion of the Caregiver Protective Capacity form and all other relevant parental behavioral health documentation. A training curriculum based on qualitative data from behavioral health providers was developed and piloted with 23 behavioral health providers. This report presents results of Phase 2 of the study, which aimed to identify behavioral health providersâ&#x20AC;&#x2122; capacity, and determine their training and system-level needs to effectively address behavioral health issues in parents involved in Circuits 2 and 4 of the child welfare system. The following specific research questions were investigated using a mixed-methods approach: 1. What is the current capacity of behavioral health providers in the circuit to address parental behavioral health issues linked to child well-being, safety, permanency and future referral to the child welfare system? 2. What training and system issues facilitate or impede the ability of behavioral health providers to adequately address parental behavioral health issues related to key child welfare outcomes? 3. What is the adequacy of current practice in determining specific parental behaviors that have been linked to child safety, permanency and well-being outcomes, including risk for future child welfare referrals? For example, how effective is the caregiver protective capacity assessment? How well are case managers conveying the specific parental behavioral needs to the behavioral health provider?

Background To promote successful outcomes in child welfare practice, the behavioral health needs of parents involved with the child welfare system need to be addressed. Therefore, Phase 1 (Fall 2016 – Fall 2017) and Phase 2 (Fall 2017 – Fall 2018) of this project aimed to identify and address the gaps and needs for behavioral health integration among behavioral health providers and child welfare personnel. A systematic review and analysis of child welfare records was conducted during Phase 1. Focus groups were held with providers in the primary Medicaid-serving behavioral healthcare center and the child welfare case providers within the Circuit 2 Managing Entity, and the results were analyzed. The review of these case records and focus groups revealed that behavioral health providers perceived the need for further training to understand how to effectively work with and increase the motivation of parents involved in the child welfare system, especially parents affected by trauma. The case records reviewed revealed that most parents sampled had significant and relatively high rates of substance use, interpersonal violence and other trauma history, as well as mental health and medical problems. In many cases, there was substantial co-occurrence of these risk issues. Most parents were referred for multiple services, but there was inadequate information of service follow through. It was evident from both the qualitative and quantitative results that parental engagement in evidence-based treatments for mental health and substance abuse is problematic and indicates a need for improvement. Phase 1 results also revealed that child welfare personnel perceived limited knowledge or utilization of evidencebased screening tools to detect parental behavioral health issues. This report presents results of Phase 2 of the study, which aimed to identify behavioral health providers’ capacity, and determine their training and system-level needs to effectively address behavioral health issues in parents involved in Circuits 2 and 4 of the child welfare system. To address perceived training needs based on qualitative data from Phase 1, this year’s project piloted a training for behavioral health providers and child welfare personnel that focused on evidence-based approaches to the detection of parental substance abuse and mental health issues. The training was feasible to deliver in a one-day format, and substantially increased knowledge in the domains covered in the training as rated by child welfare case managers.

Project Description Data from Phase 1 conducted in FY 2017-18 were used to identify sources of information and documentation routinely collected to determine parental behavioral health needs and specific parental protective capacities. Specifically, a sample of Caregiver Protective Capacity Forms was examined for a six-month period from Circuits 2 and 14. All main behavioral health provider outlets in these circuits were identified through stakeholder meetings. Qualitative interviews via focus groups and semi-structured interviews with purposefully sampled behavioral health leadership staff, supervisors, and therapists were completed (n = 29). Interview guides were developed to address the research questions outlined above. Behavioral health providers were asked to enumerate their training experiences and practices in addressing parental behaviors that directly affect risk for poor child welfare outcomes, as well as protective factors.

All focus groups and trainings were audio recorded (with permission) in order to conduct qualitative analyses and training fidelity checks. Key questions based on principles of grounded theory were developed, and thematic analyses were performed. A training based on the results of the qualitative interviews was devised and piloted. The goal of the training was to strengthen the capacity of behavioral health providers to specifically address parental behaviors that influence child welfare outcomes.

Qualitative Study In-depth qualitative interviews were conducted to explore behavioral health providers’ experiences and capacity to address parental behavioral health needs. Study procedures were approved by the Florida State University Institutional Review Board. With assistance from the Big Bend Community-based Care (BBCBC) lead agency, we recruited behavioral health providers serving clients in Circuits 2 and 14. Providers who serve parents referred by the child welfare system were considered for inclusion. Providers were contacted by a member of the project team about the project and, for those who were interested in participating, interviews or focus groups were scheduled. We developed interview guides to address the first three research questions and conducted a total of 10 semi-structured focus groups and individual phone interviews, which included a total of 23 behavioral health providers, between the dates of December 2017 and January 2018. Interviews were conducted either in person or by telephone, based on preference of the interviewee. Behavioral health providers were asked to describe their training experiences and practices in addressing parental behaviors, and working with child welfare clients. Additionally they were asked to share their current practices for assessing parents’ behavioral health and parental capacities. All focus groups and interviews were audio recorded. Participants signed a consent form and agreed to be audio recorded at the beginning of each interview. Analysis Audio recorded interviews were transcribed verbatim. Analyses were conducted concurrent with ongoing interviews so that insights from earlier interviews could be used to inform queries in subsequent interviews. Our overall approach to thematic analysis was an “Editing Analysis Style,1” which contained both deductive and inductive elements. Although we identified predetermined areas of needs and opportunities for behavioral health integration, interviewers remained open to the emergence of new or unanticipated content areas and themes, based on responses to open-ended questions. The investigators independently read each interview transcript, breaking down the data into individual segments that expressed a single idea or theme (e.g., a particular barrier regarding screening for parental behavioral health), and labeled these segments with appropriate codes, as described below. We used an iterative process to compare results until agreement was reached on the categories. Once the initial codes were agreed upon, the data were imported into NVivo 11 and coded to ensure that comprehensive sets of passages/quotations were compiled for each of the agreed upon themes. We then reviewed analyzed the data for each theme and developed study findings through group consensus. 1

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A style of analysis geared toward interpretation of text to find meaningful segments.

Results

SUBTHEME 2: SOCIAL SUPPORT NETWORKS

The interviews produced a rich data set with several emergent themes. This section summarizes themes that were most salient and relevant to our initial research questions. We identified content related to six themes: 1) Beyond Parental Behavioral Health Needs; 2) Detection and Assessment; 3) Parental Behavioral Health Needs; 4) Parent Relevant Case Planning and Treatment; 5) System Issues; and 6) Training and Training Needs. We open our discussion of each theme with tables displaying the frequency of the subthemes, including the number of interviews in which the subtheme emerged and the number of times it was referenced across interviews.

Providers observed their clients lacked positive social supports and discussed their views on the importance of developing strong social support networks to maintain success after services were terminated. They described efforts to connect clients with support networks (e.g., church groups), empowerment groups for men and women, and peer support groups.

THEME 1: BEYOND PARENTAL BEHAVIORAL HEALTH NEEDS

Behavioral health providers frequently mentioned client needs that extended beyond behavioral health services during interviews. Needs that centered around case management services and life management skills training were most often repeated. The Tables in this section indicate the number of times each theme was referenced by an interviewee. Table 1. Frequency of Beyond Parental Behavioral Health Needs Subthemes

“What we want is for them to be successful when we’re not around so we have to build that support while they’re with us, whether it’s, I don’t know, to churches if that’s what they want, or whatever, you know roller derby (laughs), whatever it is that makes them feel supported.” THEME 2: DETECTION AND ASSESSMENT

Providers were asked to describe the methods they used to assess parent’s behavioral health needs and parenting capacities. Table 2. Frequency of Detection and Assessment Subthemes Interviews (N = 10)

Times Referenced

Assess Needs and Capacity

Caregiver Protective Capacities Form

Subthemes

Interviews (N = 10)

Times Referenced

Case management

SUBTHEME 1: ASSESS NEEDS AND CAPACITY

Social Support Networks

Approaches to assessing parent behavioral health needs and parenting capacities varied across providers. Some mentioned using established instruments (e.g., ACES, Child Behavioral Health Assessment, Family Functional Assessment, North Carolina Family Assessment, PHQ-9, NICHQ Vanderbilt Assessment Scale). Others referenced areas without mentioning specific instruments (common areas included trauma, family functioning, parental capacities, parenting stress, psychosocial history, substance use/abuse, etc.). Some providers described a lack of specific screeners or tools to assess parental needs or caregiver protective capacities, and/or used their own assessments, as exemplified in the following excerpts:

Subthemes

SUBTHEME 1: CASE MANAGEMENT

Providers observed parents often struggled to meet basic needs such as housing and transportation. Ensuring these needs were met was critical to parent’s ability to engage in behavioral health treatment. Helping parents achieve greater stability was thought to require a treatment approach that included intensive case management services, as reflected in the following quotes: “I see a lot of parents come in where their basic needs, their physical, emotional, their tangible needs are not met. We have a lot of parents that live in poverty or in impoverished environments, and you know, that impacts them across the board. So being able to come to appointments, having bus fare to get here, having transportation, having access to safe and stable housing. These are things that typically impact this population.” “My client needs a case manager…to address the services that they need.” Providers noted that their clients who work with case management “…have better outcomes than those that don’t.” Some of the behavioral health services agencies provided additional case management services, and providers described assisting families with services such as transportation, housing, and employment. According to other providers, case management was not provided or funding for support services (e.g., transportation) was limited. Although many clients were assigned a Department of Children and Families (DCF, Department) case manager, approaches to providing case management services varied on a “case-by-case basis” or by the case manager assigned to the client. Thus, the need for case management services was salient but the degree to which such services were adequately provided was inconsistent.

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“We just have to basically make our own informal and formal assessments.” “I mean we have our own agency, um, case management assessment, so we, um, go over demographic information, child welfare information, medical, mental health, housing, transportation, social needs, and child care needs.” Other providers viewed the use of formal assessments with some skepticism: “It’s not gonna help us to guide clinical practice at all, and just stopping us from going out into the field and actually meeting with people and doing the work that we need to do.” “So, I’m sure there are some, there may be a tool that is probably great and successful but, um, I, I think that none of those tools are going to trump meeting with your clients where they’re at and living that experience with them to help them get through it.”

SUBTHEME 2: CAREGIVER PROTECTIVE CAPACITY FORM

The research team was specifically interested in learning whether and/or how behavioral health providers were using the Caregiver Protective Capacity (CPC) Form to assess parents’ protective capacities and to guide treatment. Most providers indicated that they were not familiar with the form or that they do not consistently receive it as part of the referral packet. “One challenge is that we don’t have the Functional Family Assessment [FFA] and so we don’t have the FFA and so we don’t have the information, um, except what the DCM [Dependency Case Manager] tells us or what the client tells us.” One provider said that she/he received the CPC as part of the FFA and found it to be “…very useful because I’m also the one that approves the conditions of return.” However, overall, it does not appear that behavioral health providers are widely familiar with, receiving access to, or are currently using the CPC form.

THEME 3: PARENTAL BEHAVIORAL HEALTH NEEDS

Providers reflected on common presenting issues of their clients, treatment approaches, and the use of evidence-based practices. Table 3. Frequency of Detection and Assessment Subthemes Interviews (N = 10)

Times Referenced

Parental Behaviors and Treatment Needs

Treatment Approaches/Use of EvidenceBased Practices

Subthemes

SUBTHEME 1: PARENTAL BEHAVIORS AND TREATMENT NEEDS

Providers described the behavioral issues often addressed in treatment and the complexity of issues their clients presented. Common issues included impulse control, emotion regulation, self-awareness, aggressive behaviors, attachment issues, and co-occurring substance abuse and mental health. “…well typically, um, if we receive a referral [from dependency case management] and we initiate services for the family, um, we’re usually seeing some pretty challenging problem behaviors.” These included symptoms were thought to be associated with long-term and intergenerational trauma: “…we as a child welfare system look at these parents like why can’t they control their behaviors, and it’s like well if you look at what they’ve been through and what’s happened to them…” “Most of our families that we work with in the community mental health setting do come to us with a lot of history and a lot of intergenerational trauma…that they carry with them. And have, uh, undoubtedly transferred to their children.” SUBTHEME 2: TREATMENT APPROACHES/USE OF EVIDENCEBASED PRACTICES

Providers described approaches to providing treatment. In these discussions, interviewer(s) probed for the use of evidence-based practices. Treatment approaches varied, were often driven by provider perceptions of client needs, and did not tend to reflect

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strong adherence to a specific evidence-based practice. Instead, the use of approaches was thought to be effective for the clients’ needs. Providers discussed using practices such as motivational interviewing, peer-to-peer mentoring, behavior management, and Cognitive Behavioral Therapy. Overall, they described their approach as a ‘mixed bag’. Providers emphasized the use of strategies that were based on parents’ needs: “…I would start with the person’s, you know, major problems, rather than parenting. I mean you have to—they’ve got to fix themselves a little bit before they can help their child.” “So you’re not necessarily thinking, “I need to get these people reunified in 12 months. I’m thinking what does this parent need to work on.” Some comments reflected a movement away from manualized treatments toward what may be more consistent with a modular approach: “…they’re trying to push way from, they as in our research team, are trying to push away from evidence-based treatment and push towards some kind of, I thought it was like, effective treatment. Something like that where it shows this, as long as you can show this program is effective you don’t have to have this exact model and use it this exact way.” Other comments reflected negative views of the effectiveness of evidence-based treatment models: “Um, CBT type stuff really has been unsuccessful for the most part.” This appears to be driven by inconsistencies in the availability of training and a fluctuating emphasis on different evidence-based treatments across the field: “Money (who got the contract) drives availability of training, this can lead to inconsistencies…For two years it will be all about trauma-informed care. For two years it will be all about adoption competency. You know, and then, as you said, those people leave. So there’s been all this dedicated training under that model…and, um, then that goes out of fashion.” THEME 4: PARENT RELEVANT CASE PLANNING AND TREATMENT

Content in this theme surrounds the relevancy of case plans to parents’ needs, skills, and capacities. Parental engagement and other factors affected the providers’ ability to implement case plans and provide effective treatment thought to meet parents’ most pressing behavioral health needs. Table 3. Frequency of Detection and Assessment Subthemes Interviews (N = 10)

Times Referenced

Parent Engagement/Motivation

Unrealistic Recommendations & Expectations

Subthemes

SUBTHEME 1: PARENTAL BEHAVIORS AND TREATMENT NEEDS

Parent engagement and motivation was the most salient subtheme to emerge across categories. Providers described both the centrality of parental engagement to effective services and the challenges they encountered in engaging parents. Although providers reported varying levels of engagement across clients, it was noted as a common challenge: “System wide, I believe engagement in behavioral health programs is low.” Issues of low engagement were exacerbated when parents experienced difficulty accessing psychotropic medications not covered by Medicaid, parents’ inability to keep appointments due to lack of transportation or competing priorities, and client resistance. Resistance was partially driven by several factors, including a perceived lack of inclusiveness and feeling overwhelmed by the process: “I think they [the parents] need to feel like part of the team involved in helping get their family back. They need to feel included, um, so that they are motivated to change and, um, make their voice heard.” “…these families have a lot of folks that are involved with them. So they have, kind of a revolving door of people that are coming into their lives and, um, so they can be very, like I said, apprehensive…” Behavioral health treatment was often among the many requirements listed in the case plan: “whenever a caregiver is referred by child protective services, whether it’s the dependency case manager or the investigators, um, they kind of see us as checkbox…”. Delays in accessing behavioral health treatment was also thought to diminish motivation: “Even if they go in engaged and motivated, they’re, a lot of they lose it quickly because they have to wait so long…” Providers also observed that getting parents into treatment often increased their motivation: “Once you get them in the door, um, the buy-in increases significantly. It’s just getting them here is the hard part.” Providers noted some effective strategies for increasing engagement, including frequent visitation with their children, making the treatment centered on the parent, building a relationship with the parents, and the use of a collaborative approach to identify treatment goals: “…over fifty percent of the job is really just relationship building.” “…I allow them to feel like, yeah, you may be here because the Department said you had to come, but you have control over what you want to improve your children’s life. So I think that helps them engage more and buy in more because I’m asking them to tell me. I know what the Department says, but you tell me from a parenting perspective…this is your family; this is your child, right? So help me understand the dynamics of that and what I can do to help you reach this requirement by the Department, but also meet your own requirements as a parent and individual.”

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“…you kind of have to be a good salesman to get them to see the value in it cause otherwise it’s just another thing the case manager is prescribing that they don’t want to do.” Overall, providers expressed an understanding of parents’ lack of motivation, noting the importance of getting them into treatment as soon as possible, and utilizing relationship building skills to increase engagement over time. SUBTHEME 2: UNREALISTIC RECOMMENDATIONS AND EXPECTATIONS

Providers described case plans that had highly demanding requirements parents were often unable to meet, and a process in which parents were often excluded from decision-making. Gaps in services surfaced as an added barrier to meeting expectations: “And it’s like, “Oh, I want to go get my mental health treated. Okay, I go to get an appointment. Okay, see you in like three or four months.” Another provider described courts and case managers viewing behavioral health providers as doing the work for the parent: “So, that’s kind of catch-22. We’re telling you [the parent] that you need treatment, however, when we go to court to receive the status of your, or review your status, we’re using that treatment that we want you to do as a downfall because now they’re saying we’re doing everything for them. Well, we’re assisting them with becoming self-supportive...” (In this example, the provider was describing helping a parent with their resume and to find employment opportunities). At times, the number of services parents were expected to participate in to meet case plan requirements were unrealistic, conflicted with other priorities, or were redundant: “And so, a lot of these folk are on probation, so if they don’t pay their probation [fines] they go to jail. So it’s like, which one’s more important, my kid, yes, but if I’m in jail that won’t matter either.” “Like, um, just a couple weeks ago, um, my current child welfare treatment specialist was in a staffing, a person was mandated to have a parenting psychological assessment, a mental health assessment, and a psychiatric assessment.” Providers discussed how their clients often expressed confusion about the process and what was expected of them. This was partially driven by lack of effective communication: “I will ask them…do you understand what this assessment is for? No ma’am, nobody has really explained it to me. And you know a lot of the time they [the case manager] did but where they [the parent] are right now physically and emotionally, it’s like it went in one ear and out the other.” “I mean I’ve experienced a lot of my parents, they won’t see their case managers for extended periods of time so they don’t know when their next court date is, they don’t know what caregiver protective capacities are; they don’t know, like anything that’s going on behind the scenes. They’re told to do something, they don’t get explained why and so, of course, they’re resistant…”

Providers mentioned that parents were frequently left “dangling in the wind” due to the number of services they need to balance, along with a job and lack of transportation. High turnover and gaps in communication with case managers left parents feeling “completely left out of the process”. In addition, providers describe parents as often being unprepared for reunification due to a lack of communication between the multiple systems and the absence of an incremental reunification process. Providers thought this increased return rates within months of reunification. In other instances, there were noted discrepancies between the case plans and treatment plan. For example, a provider described a treatment plan stating reunification while the parent was in the process of having his/her rights terminated. All of this information reflects a need to create clearer communication processes with parents and across systems, and to consider the feasibility of case plan expectations for parents.

THEME 5: SYSTEM ISSUES

This theme was the most salient in terms of the number of emerging subthemes and references. Within this theme, providers discussed the ability of services to meet the needs of parents, a lack of collaboration/coordination of services for parents receiving services from more than one system or agency, and the quality and adequacy of communication with DCF. Many of the issues overlapped with subthemes within other categories. Table 5: Frequency of System Issues Subthemes Interviews (N = 10)

Times Referenced

Adequacy-Appropriateness of Services

Communication with DCF

Multiple System Involvement

Subthemes

SUBTHEME 1: ADEQUACY-APPROPRIATENESS OF SERVICES

Within this subtheme, providers commented on the lack of available services to meet clients’ needs, especially in rural locations. This included access to clinicians qualified to conduct psychological evaluations. This lack of access led to delays in the assessment process and limited the ability to develop case plans based on assessments. Behavioral health providers expressed feeling limited in their ability to have an impact given the current service structure and timeline. “As therapists, we can only do so much. I mean, we’re allowed so many sessions and so much time. And it’s really an hour here and there. Forty-five minutes here, forty-five minutes there. There needs to be more than that. Somebody that comes in and does more regular help of whatever kind is needed.” Providers shared concerns about the ability of services to meet the families’ long-term needs. One provider gave an example of a family who had four generations of child welfare system involvement as a symptom of service inadequacy. SUBTHEME 2: COMMUNICATION WITH DCF

Providers shared varying opinions about the helpfulness of the information provided by DCF that pertains to the client’s circumstances. Some stated that they must know what

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information to request in order to prevent clients from “fall[ing] through the cracks”. This requires some experience and knowledge of the child welfare system, which is not always a given among behavioral providers. They noted that sometimes the information provided in the referrals is often ‘not relevant’ or limited, that they may only receive “between a sentence and a paragraph” of information, or that they are unaware of another case plan that may already be in place. Other providers stated receiving “28 pages of information” including police reports. Reflecting on the inconsistency of the communication between behavioral health providers and DCF case managers, one provider commented: “…I know some of the more seasoned ones [case managers], I’ve been working with them for long time and we work pretty well in tandem together and they get it, but I’ve also had some other experiences that, where we’re like are we, do we have the same goal here?....we definitely get frustrated with, it just depends on who the case manager is, if they’ve got one that is not responsive or negative about the parent, it’s a challenge.” Providers also described a lack of consistency in the quality of communication. While some providers had very “open communication” with case managers, including an ability to meet in-person, other case managers lacked field experience, sensitivity, and training needed to support good communication. Difficulty in establishing rapport and effective communication between the behavioral health providers and DCF case managers was thought to be the result of high turnover rates among case managers. Although the level of communication needed varied on a case-by-case basis, behavioral health providers generally desired more face-to-face meetings and consistency in communication with case managers. SUBTHEME 3: MULTIPLE SYSTEM INVOLVEMENT

Providers described a lack of coordination across systems. Examples such as the unrealistic expectations of behavioral health providers’ role in the case by the courts—including frequent subpoenas and hourly monitoring of parents’ interactions with his or her child were frequently cited. Poor communication regarding the parents’ readiness for transition/reunification was also noted as a concern. One provider noted that parents and providers sometimes receive less than 24-hour notice to reunification, leaving little time for providers to assist parents with the transition. Providers noted that there are often: “…multiple providers serving the same clients but no one’s talking to each other. And so you might have parenting classes at this agency; individual counseling at this agency, and then you have to do, um, urinalysis and drug counseling…So you have, you know, four or five different services from four or five different providers, um, they’re not necessarily talking, um, on a frequent basis…about what they’re seeing with their client. Um, so we’re not like being able to address concerns collectively.” Several providers commented about a lack of communication between those filling different roles of the child welfare team. Without a comprehensive assessment and concurrent planning at the onset of services, behavioral health providers were sometimes surprised by the additional levels of treatment that may be needed almost a year after DCF involvement. Sometimes

restrictions by one system (e.g., schools) limited providers’ ability to access to their clients. Providers frequently mentioned the necessity for monthly meetings between all providers serving the same family. They also discussed efforts by the lead agency to build collaboration: “…I meet with a group of other providers monthly and Big Bend kind of facilitates that meeting, so the whole point is for behavioral health and child welfare to come together at those meetings and kind of talk about what’s working, what’s not. Um, but I can share that I have—I and other providers have been kind of been frustrated because the main—the main child welfare dependency case management entity in [county] is never present during those meetings.” There was a well noted lack of cross-system coordination and some efforts appeared to be in place to address the issue, yet participation was inconsistent across agencies or counties.

“…at one point or another every single one of our counselors, every single one of our, um, support staff are going to…need knowledge of the child welfare system.” Another stated, in response to a need to facilitate improved crosssystem service coordination: “I think the best thing would be just cross training so that they could get to know each other.” Providers thought it would be important for these trainings to involve “judges on the bench, magistrates, and attorneys”.

THEME 6: TRAINING AND TRAINING NEEDS

Participants reflected on how they learned about the child welfare system, discussing both formal and information training and educational experiences. This led to discussions of gaps in training and identification of training needs. Table 6: Frequency of Training and Training Needs Subthemes Interviews (N = 10)

Times Referenced

Formal & Informal Training

Training Needs

Subthemes

Providers had substantial agreement on the usefulness of receiving universal training on the 1) safety methodology; 2) child welfare system and roles, practice models and outcomes; 3) screeners and therapeutic approaches with evidence of effectiveness with parents involved with the child welfare system. More cross-system trainings and workshops were cited as needed. They highlighted the importance of all providers who serve child welfare-involved families having knowledge of the child welfare system:

SUBTHEME 1: FORMAL & INFORMAL TRAINING

Most providers indicated that they had not received formal training or education about the child welfare system. Most of their knowledge was gained through experience and described as primarily “hands on training” and “experiential”. Providers described the process of informally learning about the child welfare system by working closely with current and past case managers and through exposure to the filed. However, providers had received some training on topics that were relevant to working with child welfare-involved clients, including: CPR, fire safety, cultural competency, adoption competency, traumatic stress and grief, and in a few instances, providers reported attending a training on the safety methodology. Overall, providers’ level of training and education pertaining to the child welfare system was limited.

Finally, providers mentioned a need for training to enhance parental engagement and support building in times of transition for providers and parents, especially when it came to reunification: “And educating them on how important that transition is and they’re gonna say that they know how important it is but that’s not what’s happening in the real world.” (This provider was specifically referring to a trend where parents, children, and service providers received limited notice that the child is being reunified with the parent).

Training Development and Results A half-day training curriculum was developed based on the primary results of the behavioral health provider qualitative study. In June 2018, the Florida State University research team provided a three-hour behavioral health training entitled Behavioral Health and Child Welfare Practice Integration to contracted providers in the Circuit 2 and 14 catchment area. Forty-three (43) providers attended the training. The purpose of the training was to provide a child welfare practice model framework for delivering behavioral health services to parents with children in the child welfare system. The training focused on providing participants an overview of the child welfare system, an understanding of primary focal areas, and processes. Training components included: 1. The child welfare practice model

SUBTHEME 2: TRAINING NEEDS

2. Defining maltreatment

Providers identified several training needs. They highlighted the importance of all providers who serve child welfare-involved families having knowledge of the child welfare system. There was substantial agreement on the need for a universal training on the safety methodology. Other topics mentioned included training on: 1) the child welfare system and working across systems, 2) the child welfare practice model and outcomes, and 3) the use of validated screeners and therapeutic approaches that are effective with child-welfare involved parents. They further mentioned wanting there to be more cross-system trainings and workshops.

3. Understanding danger threats

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4. In-home safety criteria 5. Safety management 6. Caregiver protective capacities 7. Child/family functional assessments 8. A-Z questions for behavioral health providers (addresses questions from “How does someone involved in the child welfare system come to my attention?” to “Once I’m working with a child welfare involved client, who do I share information with?”)

This training was designed for behavioral health providers who work outside of the child welfare system but receive referrals for child welfare-involved clients. The training was designed to specifically address the following questions: 1. Does participating in the training increase knowledge of training content? 2. What are participants’ perceptions of the training? 3. In what ways do participants feel that the training could be improved? Pre-post qualitative data suggest that behavioral health providers can identify the challenges of providing behavioral health services to child welfare recipients; however, integrating their practice methods and processes with Florida’s child welfare practice model components requires a change in practice and perspective. Participants were asked to rate the usefulness of the training on several domains on a scale of 1 (“not useful”) to 4 (“critical to our work”). Overall, mean scores were 3.50 ± 0.6 for relevance of training material for your work and 3.58 ± 0.6 for overall satisfaction with the workshop (n = 29).

Quantitative Study In order to answer Research Question 3 (What is the adequacy of current practice in determining specific parental behaviors that directly link to child safety, permanency, and well-being outcomes, including risk for future child welfare referrals? For example, how effective is the caregiver protective capacity assessment?), we conducted a child welfare case record review, extraction and analysis of the same records that were examined in Phase I of the study (Fall 2016 – Fall 2017). Whereas Phase 1 focused specifically on any information in the case record that pertained to behavioral health needs, referrals, and follow through with behavioral health referrals, Phase 2 sought to provide information on the Caregiver Capacity Assessment completed by child welfare personnel during the course of the caregiver’s child welfare involvement. We focused Phase 2 on the Caregiver Capacity Assessment as this is a primary method used by DCF to assess various domains of caregiver capacity and functioning over time. For database security, we ensured that all data file transfer methods were secure and HIPPA compliant, and that all database connections were secure and compliant with computing standards and guidelines. Analysis We examined a final sample of 202 cases in the Florida Safe Families Network (FSFN) through the Department of Children and Families (DCF), and 171 cases that had at least one valid record were extracted. Four forms were used to extract the information: FFA-Initial (FFA-I), FFA-Ongoing (FFA-O), Progress-Update 1, and Progress-Update 2. It is possible that the information on some of the four forms was missing. The main questions for the caregiver capacity domains are the same in all four forms. However, FFA-I used 2-level scales (“Yes”/”No”) (“Unknown” was classified as missing during the data cleaning process due to the small amount). The FFA-O and Progress-Update 1 & Progress-Update 2 used an identical form and a 4-level scale (A/B/C/D). The FFA-I is completed by the child protection investigator while the forms for the FFA-O and

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Progress-Update 1 & Progress-Update 2 are completed by the ongoing case manager. Per the Florida Department of Children and Families, the criteria for scores “A” and “B” can be equivalent to the answer of “Yes” in Form 1, and scores “C” and “D” can be equivalent to the answer of “No” in each of the three forms. In the child welfare practice, for the 4-level scale, an “A” or “B” is equivalent to the caregiver meeting the specific a capacity assessed, and a “C” or “D” means that the caregiver did not meet that specific capacity domain. Due to the unbalanced numbers, the percentage within the assessments is presented to show the comparable change over time.

Results The tables and figures below present the caregiver capacity domains for which changes over time were statistically significant. The timeframes for each subsequent assessment are not consistent across participants or time but represent each assessment that was conducted with the parent. Overall, 6 out of 19 domains had a significant change and 13 of 19 did not show a statistically significant change over time. For the 2-level scale, 4 out of 19 domains showed a statistically significant change over time, and 15 domains did not show improvement over time. Table 7 shows that 4 domains among 6 cognitive questions and 2 emotional domains were significant. The remaining domains were not significant. For the Cognitive “Self-aware”, “Threats”, and “Plans”, the percentages of “D” declined over time. For the Emotional “Express”, the percentage of “B” decreased while “A” increased. The vertical bars of the distribution plots for Cognitive “Threats” and “Plans” are displayed in Figures 1 and 2 to aid in visualizing the change. Table 7: Significant 4-Level Domains—All Cases Who Had At Least 1 Record in the FFA-O, Progress Update 1, or Progress Update 2 (N = 146) Variable

Category

Progress Update 1

Progress Update 2

TIME Inside Value: Frequency/Count for Each Choice at Each Time

Outside Value: % for Each Choice Over the Total Responses at Each Time

Inside Value: Frequency/Count for Each Choice at Each Time Outside Value: % for Each Choice Over the Total Responses at Each Time Note: sample sizes vary due to missing data on forms

Figure 2. Change over Time for 4-Level Domains for Cognitive “Plans” (N = 146; P-Value from Fisher’s Exact Test = 0.0462). 100 90 80

PERCENTAGE

Table 8 shows that one behavioral question, two cognitive questions, and one emotional domain were significant. The remaining domains were not significant. Two significant cognitive domains (“Threats” and “Plans”) with 4-Level scales in Table 8 appeared significant, as well with 2-Level scales when comparing the first and last records. For each significant domain, the percentage of “No” decreased, and increased for “Yes”.

BEHAVIORAL “IMPULSE CONTROL”: The parent/ legal guardian/ caregiver demonstrates impulse control COGNITIVE “THREATS”: The parent/legal guardian/caregiver recognizes and understands threats to the child COGNITIVE “PLANS”: The parent/ legal guardian/ caregiver plans Aand is able to articulate a plan B to protect children

First Record

Last Record

118

84.89

101

72.66

P-value

0.0126 Yes

15.11

27.34

116

82.86

101

72.66 0.0406

Yes

17.14

27.34

110

78.01

66.19 0.0273

Yes

21.99

33.81

109

78.42

66.19

Yes

21.58

33.81

C 69.64%

DEMOTIONAL

“STABLE”:

57.86%

81 48.48%

The parent/ legal guardian/ caregiver is stable

0.0227

30.30%

26.43% 37

21.43%

15.91%

12.86%

10 0

In order to use the maximum information to include the initial assessment using the form, FFA-I, we uniformed the 4-Level scales from the other 3 forms by matching Score “A” and “B” to “Yes” in Form 1, and Score “C” and “D” to “No”. Therefore, we may examine the change in each domain in a broader scale with 2-levels (“Yes”/”No”). Due to the possibility of missing information at any point of time in a case, we decided to look at a broader change by comparing the first available record no matter which form served as the first, and the last available record no matter which form was observed as last. In this analysis, we only included those cases with at least two records, so that each case had a first and a last record, which resulted in 142 cases.

1.79% 2

FFA - Ongoing

7.14%

2.86% 4

5.30% 7

Progress Update 1

Progress Update 2

TIME Inside Value: Frequency/Count for Eachfor Choice at Each Time Inside Value: Frequency/Count Each Choice at Outside EachValue: Time% for Each Choice Over the Total Responses at Each Time Outside Value: % for Each Choice Over the Total Responses at Each Time

Note: sample sizes vary due to missing data on formss

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As a contrast, the vertical bar plots for the domain of Cognitive “Threats” and “Plans”, which repeated significance, are displayed in Figures 3 and 4. Figure 3. Change over Time for 2-Level Domains for Cognitive “Threats” (N = 142; P-Value from Chi-Square Test = 0.0406). 100 90 82.86% 116

PERCENTAGE

72.66% 101

70 60 50 40 30 20

27.34% 38 17.14% 24

10 0

Yes

First Valid Record

Last Valid Record

TIME Inside Value: forChoice Eachat Choice Inside Value: Frequency/Count Frequency/Count for Each Each Timeat Each Time Outside Value: %forfor Each Choice the TotalatResponses at Each Time Outside Value: % Each Choice Over theOver Total Responses Each Time Note: sample sizes vary due to missing data on forms

Figure 4. Change over Time for 2-Level Domains for Cognitive “Plans” (N = 142; P-Value from Chi-Square Test = 0.0273). 100 90 78.01%

PERCENTAGE

110

66.19% 92

60 50 40 33.81% 47

30 21.99%

10 0

Yes

First Valid Record

Last Valid Record

TIME Inside Value: Frequency/Count Frequency/Count for Each Each Timeat Each Time Inside Value: forChoice Eachat Choice Outside Value: % Each Choice Over theOver Total Responses Each Time Outside Value: %forfor Each Choice the TotalatResponses at

Each Time

Note: sample sizes vary due to missing data on forms

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Discussion and Implications for Recommendations All conclusions and recommendations should be considered preliminary as this pilot study has a limited sample size and was conducted within two specific circuits in Florida (2 and 14). Overall, this project aimed to assess behavioral health providers’ capacities and identify training and system-level needs regarding behavioral health providers’ abilities to effectively address the behavioral health needs of parents involved in the child welfare system. In addition, the project gathered information from child welfare case records specifically focused on assessments of caregiver capacities and functioning and changes over time. Examining these issues could result in a greater understanding on how specific parental behaviors that directly affect the current and future well-being, safety, and permanency of children are detected and treated. This could be useful in improving the behavioral health training, detection, and referral of case managers and supervisors involved in the child welfare system. In particular, focus groups and semi-structured interviews of behavioral health providers and supervisors in Circuits 2 and 14 were conducted to pilot a training program to increase the behavioral health providers’ capabilities in addressing parental behaviors that impact a child’s well-being. In addition to the qualitative interviews, a sample of Caregiver Protective Capacity forms were examined. This can provide additional insight into identifying the current capacity and gaps of behavioral health and child welfare providers in identifying factors that result in the risk of future child welfare involvement or concerns regarding child safety, well-being, and permanency. For example, if the Caregiver Capacity Assessments are relied upon on by the child welfare case managers to determine caregiver improvement over time, but the behavioral health providers treating the parent are unaware of those Caregiver Capacity Assessments, then it is clearly an important systemlevel disconnect of vital information. Indeed, the project found that, in most cases, behavioral health providers were unaware of the Caregiver Capacity Assessments and results that were being used by the child welfare case managers. Qualitative interviews with behavioral health leadership staff members, counselors, and supervisors were conducted to identify the types of training experiences and practices they received that address parent behaviors that directly and negatively affect the well-being of a child. Common issues described by the behavioral health providers included a lack of coordination or consistency in the quality of communication across the different roles and systems in the child welfare team. In addition to case plans with unrealistic expectations for the parents, this absence of consistent communication between child welfare personnel and behavioral health providers resulted in frequent misalignment of behavioral health care for the parent and the child welfare case plan. Behavioral health providers also mentioned that clients’ needs frequently included a varying degree of case management services and training for life management skills. Providers expressed the importance of utilizing relationship building skills to increase parent engagement and the importance of the parents developing social support networks after child welfare termination. Behavioral health providers also mentioned a varying familiarity, use, and confidence in formal screening tools to assess the caregiver protective capacities or needs of parents. Especially in rural areas, a lack of available services to meet the clients’ needs was identified.

The focus groups and interviews provided insights on the behavioral health providers’ desire to receive further training on the 1) child welfare system and roles; 2) effective screening tools and therapeutic interventions for parents involved in the child welfare system; 3) practice models and outcomes; and 4) universal training on the safety methodology. Based on the analysis of the qualitative data, the Florida State University research team provided a behavioral health training on the basics of child welfare practice to providers who receive referrals for child welfare-involved clients. This training focused on an overview of the child welfare practice model and the associated process to promote a greater understanding of caregiver protective capacities, safety management, and child/ family functional assessments. The results of the pre- and posttraining test scores demonstrated a need to change the practice and perspective of integrating the behavioral health providers’ practice processes and methods with the components of Florida’s child welfare practice model. The evaluation scores after the training were in the good to excellent range.

Preliminary Recommendations to Consider Based on the Qualitative Findings 1. Provide cross-system training on the child welfare system for all providers (especially behavioral health providers) and professionals who serve child welfare involved families. 2. Increase access to behavioral health services for parents who are involved in the child welfare system, most often funded through Medicaid. This may involve reallocating funding, identifying new funding streams, providing incentives for existing and new providers to take Medicaid clients, and ensuring these services are accessible (e.g., providing transportation services or offering appointments outside of usual business hours). 3. Create mechanisms to promote communication and collaboration between providers that are serving the same families. This may include monthly or bi-monthly meetings that are built into the case plan (e.g., monthly family team meetings). Develop and possibly require documentation of the meetings. 4. Streamline and monitor the referral to service process to ensure parents are receiving assessment and necessary behavioral health care in a timely manner. 5. Promote a shift in the practice orientation from child welfare to a family welfare system. This expanded focus recognizes the centrality of parental health, well-being, and economic and social stability to successful service outcomes. This shifting perspective is more consistent with recent federal policy that places greater emphasis on prevention and is of particular importance for increasing rates of successful

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reunification and to prevent future re-entry into care. This can be spearheaded through initiatives lead by the Department of Children and Families, community-based care lead agencies, and cross-systems trainings. 6. Promote greater consistency in trainings to facilitate greater application of evidence-based and evidence-informed practices. Effective uptake of evidence-based practices takes time but committing to ensure providers are using evidencebased or evidence-informed practice will help ensure that child welfare and behavioral health providers have the skills needed to provide effective services. This may also include engaging in additional evaluation of services by assessing both service processes and outcomes. 7. Provide cross-system trainings on validated screening tools that are manageable to implement, can be used to inform case plans. Cross-system training can also facilitate communication across providers and agencies that are working with the same families. 8. Engage in efforts to properly validate the Caregiver Protective Capacity Form to ensure its reliability and validity, and to facilitate its potential to increase efforts to improve the protective capacities of child welfare-involved parents. 9. Provide training for case managers and behavioral health providers in engagement strategies such as motivational interviewing. There was a clear recognition that parents were not always aware of the specific details of, and rationale for, their case plans. In addition, parental motivation to engage in behavioral health care was seen as a major challenge. Parents often had difficulty following up and following through with treatment and all other aspects of their case plan.

Preliminary Recommendations Based on the Quantitative Findings to Consider for Training and System Changes for Behavioral Health Providers There is a need and desire from the behavioral health providers in the regions studied for accurate and reliable information about the child welfare system, including the child welfare outcomes (safety, well-being, and parental behavioral health issues related to permanency). Behavioral health providers indicated the need and desire for additional training in evidence-based approaches to behavioral health treatment, especially among substance abuse providers. Coordination between behavioral health providers, child welfare case managers, and other parties (e.g. courts) is a challenge— information exchanged between behavioral health and child welfare is inconsistent.

Across both Phase 1 and 2 of the study, it is clear that regular team meetings involving the behavioral health providers, case managers, and the parent would be extremely beneficial and should be reimbursable time. This type of case coordination would assist in aligning the behavioral health treatment plans with child welfare case plans. 1. Pilot trainings just scratch the surface. We recommend adapting pilots based on the results and expanding the content and audience. All trainings must be customized to each region in Florida. Child welfare behavioral health providers are willing to integrate parental caregiver capacities into their treatment planning process, but they need cross training to understand the purpose and intent. 2. Increase behavioral health providersâ&#x20AC;&#x2122; knowledge of the assessments and other tools (such as treatment plans) used in child welfare, including the Caregiver Capacity Assessment Form, as these assessments are being used to guide parental decisions in the child welfare system.

Specific Behavioral Health Issues and Training Implications for Behavioral Health Providers 1. Specific case management needs were consistently seen across Phases 1 and 2 of the project as most helpful, impactful, and appreciated by the families. These needs included access to support networks, housing, financial support, resources, and employment services. 2. There was a clear need to target specific parenting behaviors, such as anger / impulse control, and provide trauma interventions (beyond trauma-informed), evidencebased treatment for psychiatric disorders including access to quality medication management. 3. There was a need for interventions to help with parental engagement/buy in, including motivational interviewing, and getting all parties on same page to help with parent awareness and involvement with their case plans.

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