ANNUAL REPORT to the Community
“I am impressed with Impact System of Care’s accomplishments. Impact is transforming mental health services for youth and families in their community. The child- and family-serving agencies that form Impact are working with families in a true partnership. The Impact staff and partners now can take what they have learned to help other communities grow their own Systems of Care.” Gary M. Blau, Ph.D. Chief of the Child, Adolescent and Family Branch of the Center for Mental Health Services 1
This Annual Report to the Community provides an overview of progress toward the initiative’s six outcomes.
• Youth involved in the Impact System of Care are showing unprecedented improvement in their Child and Adolescent Functional Assessment Scale (CAFAS®) score. • Satisfaction with family life improves for caregivers and youth involved in Impact.
Impact, Ingham County’s System of Care initiative, has had a transformational year in its support of 127 youth with Serious Emotional Disturbance (SED).
• The support provided by Impact reduces the need for out-of-home placements for youth with SED. • Community resources are used efficiently for home – and community-based services that help youth stay in their homes. • More families and youth are involved in substantive ways in the development of the Impact System of Care. • Caregiver and youth satisfaction with services is very high. • Materials have been developed to help spread the word about Impact and the transformation of services for youth and families. • Impact established a partnership with Michigan State University to incorporate the System of Care philosophy within the MSU School of Social Work curriculum. • Twenty Impact managers completed a unique, yearlong Change Management leadership training experience that will serve as a model in System of Care communities across the country. • The initiative gained national recognition at the National System of Care Training Institutes in Anaheim, California, with family members and staff presenting or co-presenting 10 workshops and winning two Honoring Excellence in Evaluation Awards.
Impact is Ingham Countyâ€™s System of Care, a partnership of child- and family-serving agencies working in cooperation to provide coordinated services for children with Serious Emotional Disturbance (SED) and their families. The main goal of Impact is to build and enhance home- and community-based services for young people with SED, who are at risk of out-of-home placement, and their families. The Impact initiative was funded in 2005 by the federal Center for Mental Health Services to create a System of Care for children and youth with serious emotional and behavioral needs. During the six-year project, the Impact partnership of child- and family-serving agencies are working with families and youth to strengthen homeand community-based services and supports for youth with Serious Emotional Disturbance. 3
Maximized functioning of children with SED & their families
Impact youth make impressive gains in daily function
Ingham County youth who completed Impact services in the past year have shown more improvement in their daily function than Kay Hodges has seen since she authored the tool the initiative uses to assess youth with Serious Emotional Disturbance (SED).
“The Impact data far exceeds the state average and is the largest percentage of improvement that I have seen since the measure was created,” Hodges said. “It’s the best that has ever been achieved in Michigan and possibly even in the country.” Eighty-three percent of youth served by Impact had a clinically meaningful reduction in their Child and Adolescent Functional Assessment Scale (CAFAS) score at the time their case was closed. That’s up from 75 percent last year. And 32 percent of youth served by Impact do not have SED at the time of exit. That number was 31 percent a year ago. Hodges, who serves on Impact’s Scientific Advisory Team, said the percentage of youth who no longer have SED is particularly impressive because Impact youth tend to start with higher CAFAS scores. “This suggests that the partner agencies are collaborating and coordinating effectively to deliver the right services to the kids,” she said. “This reflects well on the Impact partners.”
“We all are getting better at what we are doing,” said Char Beedle, Family Guidance Service supervisor. “Child and Family Teams are engaging families more effectively, so they aren’t so eager to end services. They want to make sure the gains hold.” I.
CAFAS scores showed a clinical meaningful reduction
’07–’08 ’08–’09 100%
There has been an increase in Impact youth with CAFAS score improvements from 2008 to 2009 data. 4
There has been an increase in Impact youth who no longer have SED at their time of exit from Impact.
Background on CAFAS The eight domains that CAFAS measures are school, home, community, behavior toward others, moods/emotions, selfharmful behavior, substance use, and thinking. Scores range from 0 to 240, with scores of 50 and above indicating SED. Youth with scores of 80 and above meet the criteria for Impact, meaning they have SED with a risk of out-of-home placement.
Characteristics of youth being supported by Impact
Other or unknown
What Is Serious Emotional Disturbance (SED)? Overall level of functioning improved over the course of 24 months 100% 77% 61%
I am better at handling daily life. My child is better at handling daily life. Source: Longitudinal Outcomes Study
These are the signs to look for in a child: •
Has a hard time learning
Has a hard time making and keeping friends
Is angry a lot
Often seems sad or hopeless
Has lost interest in things he or she used to enjoy
Avoids friends or family and wants to be alone all the time
Often hurts others, destroys things, or breaks the law
Refuses to follow directions and often makes poor choices
Any child can have these signs for a short time, but over a longer time such signs can indicate a mental health concern such as SED. Impact can help determine whether a child has SED.
Family life improves for youth and families
Impact recently started looking at Caregiver Strain Questionnaire (CGSQ ) data as an additional measure to better determine the level of overall functioning of youth being served. It is administered at intake and at all follow-up interviews as part of the Longitudinal Outcomes Study (LOS). The CGSQ assesses the extent to which caregivers are affected by the special demands associated with caring for a child with emotional and behavioral problems. The proportion of caregivers who show an improvement in their CGSQ global strain score increases with each subsequent interview interval. At the six-month interview, 33.8 percent had improved. By the 18-month interview, 47.1 percent had improved. The CGSQ comprises three subscales: 1. Objective Strain, which refers to observable disruptions in family and community life; 2. Subjective Externalized Strain, which refers to negative feelings about the child, such as anger, resentment, or embarrassment; 3. Subjective Internalized Strain, which refers to the negative feelings that the caregiver experiences, such as worry, guilt, or fatigue. Outcome one
Satisfaction with family life improves for caregivers and youth over time as well. At the six-month interview, about one-third of caregivers said they agree or strongly agree that they are satisfied with their family life right now, with that increasing to 49 percent at 12 months, then remaining steady at 50 percent at 18 months. At the six-month interview, the majority of youth (59 percent) said they agree or strongly agree that they are satisfied with their family life right now, with that increasing to 69 percent at 12 months and 77 percent at 18 months. While the question asked is on satisfaction with family life â€œas a result of the services my child and/or family received,â€? caregiversâ€™ responses may be influenced by other stressors on family life that do not affect the responses by youth.
Overall family life satisfaction improved over the course of 18 months 100%
77% 69% 59% 49%
Caregiver: I am satisfied with our family life right now. Youth: I am satisfied with my family life right now. Source: Longitudinal Outcomes Study
More families participate in Impact evaluation
Impact youth and families are participating in the Longitudinal Outcomes Study (LOS), the largest study of children’s mental health in the world. The 2008-2009 fiscal year marked the first time the majority of families receiving services participated in the LOS. A new approach to make sure families are invited right away to join the study has been credited with the increased participation. The study is part of the evaluation that is required by the Center for Mental Health Services, which provides the federal grant that supports Impact. Families and youth served by Systems of Care across the country make the LOS possible. The information gained from the study helps Impact and other Systems of Care determine how best to provide services. Caregivers and youth 11 years old and older who join the study are interviewed when they begin receiving Impact services. Then, every six months for up to three years, they are asked about their experience with Impact and whether they are experiencing improvement in their lives as a result of receiving services.
Percentage of families participating in the Longitudinal Outcomes Study (LOS)
Impact helps youth stay in their homes
Something in the Impact data last year caught Ingham County Department of Human Services Director Randy Rauch’s attention: Neglect or abuse case Reduced need youth referred to Impact in the 2007–2008 fiscal year all were able to stay in for out-of-home their homes without further Child Protective Services (CPS) complaints.
The Department of Human Services (DHS) is one of two agencies that refer youth to Impact services. “This data shows us how to better identify the right kids to refer to Impact,” Rauch said. “We can keep youth with their families and provide adequate supports, and avoid removal.” “We think if we do this correctly, we should have many, many fewer removals,” Rausch said. That ultimately leads to better outcomes for youth and families and will reduce the burden on foster care. This, of course, leads to better outcomes for families and saves the county money. Based on the promising work Impact is doing, the pilot program is being paid for with state and federal funds. That means more local youth and families can be served without the need for additional local resources.
Outcoms two + three
Court has baseline data
Ingham County Circuit Court - Family Division, which makes the bulk of the referrals to Impact, now has baseline data on new delinquency petitions for referred youth. Of 181 youth referred to Impact by the Court as of November 2008, 69% have not had a new delinquency petition on file with the Court since intake into Impact services.
“Every community needs this if you can get it.” Randy Rauch, Director Ingham County Department of Human Services
Efficient use of resources
Court uses resources to help youth stay on track in the community
As they work together, Impact partners look for ways to use community resources efficiently. Ingham County Circuit Court–Family Division had a unique opportunity to redirect its staffing this year when an In-home Detention staff position was vacated. Instead of filling this position, the Community Placement Program was created and two part-time compliance officers were hired to give youth more supervision in the evenings and on weekends instead of sending them to residential treatment. “By checking to see that kids are where they are supposed to be, any issues can be identified right away and triaged,” said Sara Deprez, the Court’s Juvenile Programs director. Youth are referred to the Community Placement Program by a judge or the Court committee that determines if a youth needs out-of-home placement. There have been six referrals so far. The youth and their caregivers also are referred to Impact services. “This program is only for youth at risk for residential placement,” Deprez said. “We have seen an immediate reduction in out-of-home placement because of it.” Youth are required to be in school, in the Court’s Pride extended after-school program at the Ingham County Family Center, at home, or participating in a Court- and parentapproved activity. There is a community placement team that monitors youth behavior based on established criteria. Over time, youth who meet the criteria can reduce the number of hours they spend each week in prescribed activities.
Youth are rewarded for positive behavior.
Thus far, no new court petitions have been filed against any of the youth. The youth know that they will go to residential placement if they don’t comply with the Community Placement Program rules. If that happens, a review board will pick apart the entire case to see what went wrong and what went well.
“The program is new,” Deprez said, “and, though it is too early for the data to show it, the program appears to be quite effective.”
“Fewer youth are being sent to out-of-home placement because we have Impact.” Judge Janelle A. Lawless, Presiding Judge Ingham County Circuit Court–Family Division
Increased participation of families & youth in the development of the System of Care
Family and youth participation helps Impact grow
Impact is built around mechanisms to support family and youth participation. In keeping with Impact values, caregivers and youth are intentionally involved in the development of the System of Care to make sure it is family-driven and youth-guided. One of the most striking developments in the last year is the increase in the number of family members employed by Impact as a result of their involvement in the initiative. Most of the positions are part-time, but combined equal 10.5 paid fulltime positions. Their work includes encouraging other families to get involved, helping with data collection and evaluation, and serving as mentors and family advocates. Parents also are paid to facilitate the Love and Logic parenting course, and youth and parents are paid to co-facilitate Dialectical Behavior Therapy groups. This kind of substantive involvement is the goal, versus sheer numbers. Youth and family members are able to use these opportunities to empower themselves and provide leadership in the System of Care.
Youth and family involvement includes: Outcome four
IMPACT VALUES 10
Conference participation at the local and national level
Power of We Consortium
Children’s Mental Health Awareness Day
Co-facilitation of trainings
County Commissioner meetings
New employee orientation
Report to the Community
City Council meetings
School Board meetings
Parent Leadership Institute sessions through Impact
Participation in Evaluation Discussion Groups
Stakeholders governance meetings
Speak Up, Speak Out youth speakers bureau
• Family-Driven • Youth-Guided • Accessible and High-Quality Services
• Individualized Care • Coordinated Care • Collaborative Care
• Culturally and Linguistically Competent Services
Through the Impact Family Council and Speak Your Mind youth council, family members and youth are encouraged and supported to become champions who advocate for children with mental health needs. Youth and families also regularly review materials and processes to ensure they are in youth- and family-friendly language and formats. There has been a long-standing commitment among Ingham County agencies to promote family and youth involvement, but the Impact initiative has provided mechanisms for a qualitative evolution in participation.
Parent and youth involvement extends to Impact partner agencies: •
Youth on advisory board for Ingham County Family Center
Team decision-making at the Ingham County Department of Human Services
Family Advocate is a member of the Community Placement Program team at the Court (parent-facilitated Community Placement Team)
Parent groups at the Ingham County Family Center
Parents Coffee Club at Community Mental Health of Clinton, Eaton, and Ingham Counties (CMH)
Association for Children’s Mental Health (ACMH) Parent Leadership Camp
ACMH Youth Leadership Camp
Caregivers fill 10.5 paid positions: •
2 full-time equivalents (FTE) promoting youth and family involvement
5.5 FTE providing direct service to families through the Family Advocate Support Program
1 FTE data collection and evaluation
2 FTE parent mentors
Impact has served ...
127 new youth during the 2009 fiscal year,
two more than its set goal. 411 youth since fiscal year 2006,
61 more than its set goal.
OUTCOME 5 A unified, family-driven, youthguided and culturally and linguistically competent System of Care for children with SED
Family satisfaction tied to time in Impact
Caregiver and youth satisfaction with Impact services increases over time, according to Longitudinal Outcomes Study (LOS) data. Youth and families are interviewed at six-month intervals.
By the 18-month interview, the proportion of caregivers and the proportion of youth who agree or strongly agree that they helped to choose their own services have both increased. About 92 percent of caregivers and 69 percent of youth agree or strongly agree that they helped to choose their own services. By comparison, at the six-month interview the numbers are 67 percent and 49 percent, respectively. Between the six-month and 12-month interviews, there is an increase in the percentage of caregivers who are satisfied with services, say they got the help they wanted, and say they got as much help as they needed. Between the six-month and 12-month interviews for youth, there is a decrease in the percentage of youth who are satisfied with services, an increase in the percentage of youth who say they got the help they wanted, and no change in the percentage who say they got as much help as they needed.
Outcome f ive
Family Advocacy Support increases
Satisfaction with Family Advocacy Support was at its highest level in the second quarter of the 2008–2009 service year (January through March 2009), with 94 percent responding that the Family Advocate support met the needs of their child and/or family “moderately well” to “extremely well.”
Family Advocacy Support is optional, so this question is only asked of those who have received Family Advocate Services in the six months before the LOS interview. Results are expected soon from a Michigan State University study of the effectiveness of Family Advocacy Support. Providing high-quality services is one of Impact’s values.
“Ingham County has been on this steady evolution toward the development of a comprehensive System of Care that is based on values that are responsive to the individualized needs of our children and their families.” Debbie De Leon Chairperson, Ingham County Board of Commissioners
Youth and families say they feel respected by service providers More than 90 percent of caregivers say Impact service providers respect their family beliefs and understand family traditions, according to Longitudinal Outcomes Study (LOS) data.
At the six-month interview, the majority of caregivers (91 percent) and youth (81 percent) agree or strongly agree that providers treated them with respect.
At the 12-month interview, this increased to 97 percent for caregivers and decreased to 77 percent for youth.
At the 18-month interview, 92 percent of caregivers and 85 percent of youth report that providers treated them with respect.
Sixty-four Impact partner staff members have completed two cultural proficiency training modules since October 2008. Impact’s Cultural Coalition and Learning Community worked together to create the training modules. The training sessions are set up as dialogues that focus on five intersections of privilege and oppression – white privilege, male privilege, age-related privilege, heterosexual privilege, and able-bodied privilege. Cultural humility was added to the dialogue sessions this year to provide staff with a framework for engaging families. Cultural humility acknowledges that families are experts when it comes to their beliefs, practices and traditions, and emphasizes turning to the families as the best resource. An added benefit is that the sessions allow staff from the partner agencies to better understand the different agency cultures and build relationships that facilitate collaboration when supporting families. “We look at cultural proficiency on individual, agency and community levels,” said Juaquin Sanchez, Impact cultural and linguistic coordinator. An individual’s cultural proficiency can vary depending on whether one is talking about race, sexual orientation, gender, or other cultural differences.
“The cultural proficiency continuum is a journey,” Sanchez said. “Proficiency includes taking positive and affirmative steps, and we are striving to get there.” Staff and family members serve as facilitators for each module, which makes the training sustainable.
Module One Building Awareness: An Introduction to Cultural Proficiency
Module Two The Forces that Impact Life Outcomes
Module Three Agency Culture and Rapport-Building with Families
The facilitators get quarterly training on the five areas of privilege and oppression, System of Care values, and facilitation techniques. Module Three has been developed and will have trial runs in November. 13
Outcomes f ive + six
OUTCOME 5 continued
More families seek Family Advocates
An increasing number of Impact System of Care families are asking for Family Advocates to partner with them as they navigate services and systems with their children. Family Advocates partner with families to support, educate, and empower them to voice their needs, develop positive relationships with service providers, and develop skills to navigate the mental health, court, and child welfare systems. Advocates are parents or caregivers who have experience caring for children with serious health challenges. They use their own experience to help other families develop natural supports. Impact doubled the number of Family Advocates from three to six during 2008-09 and is planning to hire at least three more.
Stakeholders want the System of Care to succeed and to be a part of that success. Source: Impact partner agency discussion groups
OUTCOME 6 Increased community knowledge of the System of Care and decreased stigma
Unified voice essential among Impact partners
The System of Care concept still is relatively new and evolving in Ingham County, so it is important that Impact families, agency partners, and community-based organizations speak in a unified voice about the initiative. To explore what is working well and what could be improved in the System of Care, discussion groups were convened that included staff of the Impact partner agencies, caregivers and youth. The group comments were shared widely among Impact stakeholders, including youth and families and partner agencies.
Key Impact successes cited in the discussions included:
The challenges cited include: •
Communicating a clearer understanding of what Impact and all of its services mean to parents and their children
Improving communication among agency partners and Child and Family Teams to better coordinate efforts
Greater understanding by each partner of process and procedures
Continuing to make the intake process and the development of family plans move more smoothly and quickly
More clarity of the roles of staff from each partner agency
Increased collaboration among partners as they combine their efforts to work with youth and families
A sense of shared responsibility for the youth and families served
An increased level of accountability among the partners
Increased access to resources among all of the partners
Belief in the System of Care philosophy
Desire for the System of Care to succeed and to be a part of that success
Trust that challenges will be worked out in time
An orientation video was produced for incoming families and youth.
A more inviting and engaging Impact brochure was created to explain the Impact philosophy and services.
Staff roles were highlighted in Impact newsletters.
A folder highlighting System of Care values was created to hold all of the information that families and youth receive at intake to encourage them to value and use the resources inside.
Staff roles are discussed at monthly manager and frontline staff luncheons.
Talking points were developed so that staff use common messages to help families and youth understand Impact.
Follow-up group discussions are being scheduled to see how these and other efforts are working. 15
“At first I was apprehensive and thought, ‘My kid got in trouble, not me. Why do I have to do this?’ But I have learned how to deal with him better and I like [the parent group] now for the support it provides. I also realize that we are not the only ones out there going through this. My son is learning a lot, too, because his whole attitude is changing.” Olivia King Parent of Youth in Community Placement Program
for war d Studies show that children and youth with SED make big improvements at home, at school and in their community when they have the coordinated, community-based services and supports provided by a System of Care. Impact provides the kind of care that has proven most likely to help young people and families have lifelong success.
Impact plans for the next year include: • Increasing commitment to shared risk All team members – CMH, Court, DHS, and other partners – have to be equally invested in the risk associated with serving youth with challenging behaviors and maintaining them safely in the community. • Continuing our commitment to being outcome-driven We’ll keep evaluating how families are doing and make appropriate modifications to the services and supports they receive.
The art pictured in this Report to the Community is part of a traveling exhibit created by Ingham County youth in recognition of Children’s Mental Health Awareness Day. Their paintings and masks are on exhibit through April 2010. To see which Impact partner has the art on exhibit at any given time, go to the gallery page of the Impact website: www.impactsystemofcare.com.
• Maintaining our Continuous Quality Improvement (CQI) process Getting better and better is a process and we will continue using data to inform us of our progress in all areas. • Continuing to invest in community-based placements Whenever it is possible to maintain youth safely in the community, we will do so, because that is where they do best. Ingham County Circuit Court– Family Division recently started a Community Placement Program to keep youth out of residential placement, and foster parents are being recruited for a new Therapeutic Foster Care program for youth at risk of being placed in treatment facilities. • Developing greater capacity for crisis response Crisis can happen at any time, any day of the week. We need to respond accordingly. • Continuing commitment to moving from good to great We want to learn from what goes well and from the challenges we encounter.
I M PAC T S TA K E H O L D E R S Youth and Families from Ingham County Association for Childrenâ€™s Mental Health Boys & Girls Club of Lansing Child and Family Services - Capital Area Community Mental Health Authority, C-E-I Cristo Rey Community Center Highfields, Inc. Ingham County Circuit Court - Family Division Ingham County Department of Human Services Ingham Intermediate School District Lansing Police Department Lansing School District TM
Lutheran Social Services St. Vincent Catholic Charities