List of Interviewees:



List of Interviewees:29 Interviews total of 34 IntervieweesFirstLastTitle/OrgNotes Included?KatieAlbrightCEO, Safe & SoundYesKamalaAllenVice President for Program Operations, Center for Health Care StrategiesYesMayraAlvarezExecutive Director, Children's PartnershipNo (awaiting approval)JoaquinArambulaState Assemblymember, 31st Assembly DistrictNo (awaiting approval)VeenuAulakhPresident, Center for Care InnovationsYesMelissaBaileySenior Fellow, Center for Health Care StrategiesYesDannaBassonDirector of Research and Evaluation, WestCoast Children’s ClinicNo (awaiting approval)JimBeallState Senator, 15th Senate DistrictNo (awaiting approval)KatyBourgeoisDirector of Aligned Impact, Mission CapitalNo (awaiting approval)SheilaBoxleyExecutive Director, The CAP Center/Strategies 2.0YesJeremyCantorSenior Consultant, JSIYesDominicCappelloCo-Director, Anna, Age Eight InstituteYesKanwarpalDhaliwalAssociate Director, RYSEYesJoyceDorado, Ph.D.Co-Founder and Director of UCSF HEARTS ProgramYesMichelleDoty CabreraED, CBHDANo (awaiting approval)MaryDozierChair in Child Development, University of DelawareNo (awaiting approval)RajniDronamrajuSenior Manager, Charitable Giving, GenentechYesKenEpsteinTrauma TransformedNo (awaiting approval)TobyEwingMHSOACNo (awaiting approval)MalcolmGainesSenior Clinical Project Director, Safe & SoundYesShawnGinwrightConsulting, California EndowmentYesStaceyKatzCEO, WestCoast Children’s ClinicNoJodie LangsAssociate Director of Research & Policy, WestCoast Children's ClinicNo (awaiting approval)DaynaLongUCSF Benioff Children's Hospital OaklandNo (awaiting approval)ThomasMackieRutgers University Center for State Health PolicyNo (awaiting approval)ElizabethManleyUniversity of Maryland, School of Social WorkYesFrankMeccaExecutive Director, CWDAYesSaraMunsonSenior Director of Knowledge ManagementSystems Improvement, Casey Family Programs,YesDr. KatherineOrtega CourtneyCo-Director, Anna, Age Eight InstituteYesPeter JPecoraManaging Director of Research Services, Casey Family Programs / University of Washington School of Social WorkYesJenniferRodriguezExecutive Director, Youth Law CenterNo (awaiting approval)BryanSamuelsExecutive Director, Chapin HallNo (awaiting approval)ChrisStoner-MerzExecutive Director, CACFSNo (awaiting approval)PamelaWinkler TewSenior Program Officer, Center for Health Care StrategiesYes TOC \h \u \z List of Interviewees: PAGEREF _u2140kd30mpn \h 1Interview Notes that have been approved/reviewed to share with partnersKatie Albright and Malcolm Gaines, Safe & Sound PAGEREF _nz79zm4bdxea \h 4Kamala Allen, Melissa Bailey, Pamela Winkler Tew, Center for Health Care Strategies PAGEREF _clhmiamdlcf6 \h 11Veenu Aulakh, Center for Care Innovations PAGEREF _473acd4s2k7 \h 14Sheila Boxley, the CAP Center/Strategies 2.0 PAGEREF _p7nlhwlutbww \h 18Jeremy Cantor, JSI PAGEREF _r4h92pwekqep \h 22Dominic Cappello and Katherine Ortega Courtney, Anna, Age Eight Institute PAGEREF _lpmsgfqy8fbx \h 25Kanwarpal Dhaliwal, RYSE Center PAGEREF _d0zv5gvkazqa \h 29Joyce Dorado, UCSF HEARTS PAGEREF _ollj07md2h9m \h 33Mary Dozier, University of Delaware PAGEREF _mk5lptxrpth9 \h 37Rajni Dronamraju, Genentech PAGEREF _kzskwpr8t2t4 \h 40Shawn Ginwright, Flourish Agenda PAGEREF _lis2131gaym9 \h 44Elizabeth Manley, University of Maryland School of Social Work PAGEREF _ldj8dhm4upvk \h 49Frank Mecca, CWDA PAGEREF _89xy8stox4nj \h 53Sara Munson, Casey Family Programs PAGEREF _zgi4har4wzwt \h 58Peter Pecora, Casey Family Programs/University of Washington School of Social Work PAGEREF _q5y58h55ifaj \h 61Interview NotesKatie Albright and Malcolm Gaines, Safe & SoundName,Org & TitleKatie Albright, CEO, Safe & SoundMalcolm Gaines, Senior Clinical Project Director, Safe & SoundQuestions for All Interviewees:What programs do you know of that work to mitigate trauma and promote healing and why are they successful? (Not just programs in California). Laurie: we’d like to either provide and inventory or characteristics of programs for community providers, and those responding to indicators of ACEs.Katie: First let's frame how we think about protective factors. We see Protective Factors as the answer to “what do you do now” once you know someone’s -- or a family’s -- ACEs score We see Protective Factors manifesting on a micro individual or family level and also on a macro level -- a community level. Ultimate, we see a future of care here that would build community and individual protective factors across California. Malcolm: Of the original 10 ACEs, half were around child abuse. When we think about ACEs, we think about intergenerational prevention. The protective factors model, first published in 2003 from the Center for the Study of Social Policy, has a “strengthening families” focus. The protective factors are:Parental resilienceSocial connectionsConcrete support in times of needKnowledge of parenting and healthy child developmentSocial and emotional competence of the childWe organize our service delivery and outcome measurements around supporting families to build these protective factors. These tools assess where families are in terms of these in their lives, and pair that information with an understanding of ACEs and vulnerabilities in their lives, certainly for the families, and also as individuals -- where are the parents? We use the protective factors model to look at the family's strengths and resiliencies side by side with the risks. Then we say “okay now we know what do we do? How do we build up your family strengths to mitigate the trauma?: We look at the resiliency factors, and the specific risks of the family.If the family or individuals have symptoms of trauma, how do we build a response, create the conditions for trauma recoveryWe want to prevent the transmission of trauma through the family.Laurie: So you must have some other assessment tool that you use to respond?Malcolm: Yes, we have a few specific tools that we use. There are some we are using now, some that we used in the past, and some that are in development. The tools that we use look at the family as a whole. We think of the 5 domains of family functioning, as a way of thinking about resilience in a particular case and preventing child abuse in a family context.Parental resilience is one of the protective factorsAnd you can think about the other 4 as supporting resilience in a broad family settingI do want to make the distinction between assessing a family functioning vs. assessing resilience or factors for individuals. Often you might look at the resiliency of an individual as distinct from a familyWe look at the five protective factors together as a way of assessing the resiliency of a family.Katie: Malcolm, what do you think about the two-gen, total resiliency of a family? Why do we start there?Malcolm: Usually we start with the adverse experiences of the caregivers of the family, how that is affecting their experience of caregiving and their functioning. If there are adverse experiences in the children in the family, how can we help the parents deal with the child’s individual ACEs. And how do we prevent the transmission of ACEs from the family to the child?How do we look at a parent’s adverse experiences, and support their recovery using a trauma recovery modelThat would be working on one of the protective factors, parental resilienceWe are always keeping in mind the protective factors as building resilience as a whole.Laurie: So are you always thinking in terms of two-gen? For example if a family comes in and there is an indication of domestic violence, would you think about treating the adults and the children?Malcolm: So one member, a survivor of the violence, might come to us and want support For example if they’ve left the relationship and need access to resources, we are going to provide some case management services and supports around that; we are probably going to do some parent education around the effect of the experiences on the child and some parent education on ways to think about if their child is having a hard time We also provide mental health services for deeper trauma recovery work. We offer mental health services and support for the child. We would also work on the family’s social connections through family events and weekly dinners. So there are ways that the family -- the parent and the child -- can reconnect, so they’re not isolated, especially if they're leaving a situation related to DV. If a child is school-age we may not see them very often, but we are always putting a two-generation approach in mind. We will incorporate that in our service plan, even if we don’t have eyes on the child.Katie: With two-gen, it's not just programs delivered to kids and adults -- it's trying to drive towards outcomes for both generations, that intergenerational piece. There are many programs that provide support to parents and children, but when we approach two-gen, we ask: do the programs deliver outcomes for the child and for the caregiver? That’s why we like the 5 protective factors -- they are intergenerational.Laurie: Have you done shareable evaluations that we could point to that would say this “makes for a good Family Resource Center, something that shows outcomes intergenerationally.”Katie: That is something that we are trying to move towards, especially when you're talking about the macro level. I can tell you about where we are. I really think family resource centers as a whole in CA have focused on the 5 protective factors approach. Family Resource Centers are working at the macro level, looking at how you create an evidence base around family resources centers. One of the issues with that is that all family resource centers are unique. But there is thoughtful research from Chapin Hall on programs in Allegheny, Pennsylvania . There is some work that Casey Family Programs has are doing work in Orange County. And we have done our own internal work and we can share our numbers with you. We are working towards evaluative approaches for San Francisco’s 26 FRCs, which together have been recognized by Casey as a promising practices, as well as by the ACF’s Children’s Bureau. They have written some interesting things around prevention models in and out of California (1) what's happening in SF and (2) what is happening around the country.Laurie: With FFPSA getting rolling in the next year or two, there’s going to be quite an emphasis on whether a program is evidence-based, well-supported, and promising.Katie: We’ve been focused with our county partner in Child Welfare, and we are very aware of this. SF, like other counties, is very well-aware around the evidence-based requirements around Family First. Currently, there are 26 family resource centers funded by a blending of agencies. We’ve applied for a grant from the feds, we’ll find out soon if we get it. In any case, it will take several years of course to build up the evidence. I mention all of that, but none of that is getting to the broader issue about what is the evidence base as a field.Laurie: Are you working with Bridgette Leary?Katie: Yes, she’s moving to Urban Institute. Potentially we’ll still be working with Bridgette if we get the federal grant.Laurie: what would a performance based system of care look like to prevent and intervene with the effects of trauma. We want to look at the physical health side, and then the behavioral health outcomes, and from the child welfare perspective, some sort of dashboard.Some of the work that has been done with continuous quality improvement. How do we know that our responses are actually being effective?Katie: While we’re thinking on that one, I want to touch on 3 things, I’m sure there are programs you know about, but it's important to look at home visiting, and evidence- based parenting programs -- Triple P and the UCSF program (CTRP?) Some of the important dashboard indicators one would track would the protective factors. In terms of child welfare. ou have to look at cases that haven’t entered the system at all, and declining reentry particularly with 0-5 You’d want to look at some interesting work with Emily Putnam-Hornstein, what she’s done in this particular area.The key point is that protective factors are measurable.Malcolm: When you talk about measuring performance, Katie pointed us back to the protective factors for that. I would add about protective factors and using a trauma recovery model, -- those things fit together very well. What I mean by that:When there is trauma present, trauma symptoms present and you need to actively use a trauma recovery modelEven if there aren't any symptoms, you need to do the preventive work in building the protective factors, building the family model.So if this works, you are measuring to see how these factors are supporting the familyYou need to look at the process-based factors (QPI) and you need to look at the outcomes around change --how well you're supporting the familiesFRCs can do some or all of those things. The scope of the resources that they have will determine the ways that they support protective factors, but all FRC’s are essentially doing this work of supporting family strengths.We do this here: when families come in we talk about their needs and we ask them about their protective factors. We are not working on all the protective factors at once; we ask what the highest priority is and we use tools and data systems to capture those goals, and measurements along the way towards the goals.What are the goals, how do you try to achieve the goal? Both internally --trauma-related factors that a caregiver of a parent might be looking at -- and looking at access to services and education to make sure the processes are set up to ask those kinds of questions and measure outcomes along the way.We are still developing in the field, data around what’s the right way to measure protective factors. There are a few ways to do this.We are currently using the Parents’ Assessment for Protective Factors (Center for the Study of Social Policy). It’s a self-report tool of 36 questions, so it's a little long for some families, depending on their literacy and English proficiency. It tracks a parent’s perceptions, experiences, and feelings about protective factors. So that's the tool that we look now and we are quite happy with it and we’ve become more and more nuanced in the ways we are administering it.There is the Protective Factors Survey, also a self-reporting tool, which also measures their knowledge about parenting, how the family is functioning, etc. There is a newly published second version of this tool, but we haven’t looked at it yetThere aren’t a lot of tools out there, but those are some we are using.The PFS, the Protective Factors Survey, is in the California Evidence-Based ClearinghouseThe other one is new so it's not in the Clearinghouse yetPeople are adapting existing toolsWe’ve adapted the North-Carolina Family Assessment ScaleWas developed for use in child welfare settingsWasn’t developed for the protective factors, but the domains that it measures map well enough to the protective factors; we crosswalk the domains there to the protective factors.CANS, Child and Adolescent Needs and StrengthsSome folks have adapted CANS to measure protective factors as well.We would love to take on the case to develop another validated tool to assess child needs. There is a need to do more work on that, but we don’t have the capacity here to do that right now. Laurie: What should we be measuring, what should we look for in terms of data? E.g., mental and physical health indicators, educational outcomes, others?In terms of all of the work that the FRCs do, not just the child welfare indicators, what other indicators would you like to see measured so you can know if you’re meeting your overall goals. Is the child developing in a healthy way? Is there increased social readiness?Malcolm: What I might do to answer that is to pull some of the items from the tools we use. We use the items not just as screening tools but also at re-assessment tools. So if I’m going to take parental resilience for example, we are going to look at a parent's capacity and ability to recognize that they need help and support and ask for help and support and know where to find it. Of course, when a parent has come here, they’ve already reached out for help. We also want to support a parent’s capacity for self-regulation. We want them to be able to keep the child in mind and the child’s experience in mind so they can be aware of their capacity, and so that they know how to bring themselves back down when they’re upset so they can recognize their capacity and be able to think of something new. How can you look for help in a moment like that? This involves several things including mindfulness -- what we call mentalization, being aware of your own state of mind, your child’s state of mind. How well can someone self-regulate, how can you support someone’s development in that capacity? Social connections are another example: not just the number of connections that a child may have, but the quality of those connections. Another example: what is a parent’s knowledge of parenting techniques and child development knowledge? For instance, as a Triple P class increased the parent’s knowledge?Katie: We put together a crosswalk with the NCFAS. Of course we hope this isn’t only used around Safe and sound. We aren’t going to make the broad-scale change all on our own, but the screening tool of course could determine the broad need for services. But within the concepts of a FRC, protective factors there are powerful resources and that can be used to help improve outcomes.Laurie: I do think that this is an enormous opportunity to screen the 5-6 million kids. But some pediatricians might not know what to do with the info. They might refer to CPS. I want to give those local jurisdictions/pediatricians guidance in terms of what they should do with that information.Malcolm: I want to underscore that we are of the same mind as you about the need for support for medical providers. We are thinking about the situation that a pediatrician would find themselves in when they screen for trauma in their practice. They may see all this trauma, and their first thought due to lack of training might be refer the family to CPS. But we need to make other options available. CPS is needed in certain cases, but there is so much more that needs to happen. Laurie: So if a pediatrician knows, they might want to try to get the family to an FRC. Same with the board of supes and other stakeholders.Katie: Kaiser Medical is doing some interesting work around primary prevention; they are looking at child abuse and they are thinking about what does happen in the doctor’s office. What do you do if you see a high ACEs score? I can connect you with a person; Brigid McCaw has retired but there is another person we can share with you.Q: What advice might you have on how to finance/support programs (clinical and non clinical) to appropriately respond to the level of ACEs/Trauma in the Child Welfare population?With Child Welfare when you are talking about prevention and FFPSA the issue is candidacy. So we are not really getting into the primary prevention, to get to the IV-E funding and even EPSDT, you need a diagnosis and candidacy where you are already probably systems-involve. What mechanisms would you recommend to finance the programs you are talking about --so the pediatrician can recommend a Family Resource Center or somewhere and not rely on referrals to CPS?Katie: Without a new funding stream, it’s going to take some blending of funding streams. With IVE-Waivers, First 5and general fund, that's how we fund the FRCs, First 5 funds family resource centers in many communities. First 5 is important. Cannabis funding could also be important -- similar to tobacco tax funding for programs for kids ages 0-5, the negative impact on Cannabis use in families is pretty prominent. There is some federal funding when you think about MIECHV, and home visiting, some creative uses around home-visiting funds. There’s some interesting work around EPSDT primary uses around medical dollars being done by the California Children’s Trust. Alex Briscoe has been integral in this -- thinking about what FRCs can be in terms of delivery. Wish I could say there is just an easy funding stream I could point to, but Cannabis is maybe the only one.I would turn to Alex because SF does not draw down MHSA funding at a significant level. Because we have the generosity of the voters we don’t necessarily touch MHSA because that MHSA funding is hard to draw down. Laurie: Additional thoughts?Katie: Michelle Evans took over Brigid McCaw’s role at Kaiser, and if you need a connection we can make that happen.Kamala Allen, Melissa Bailey, Pamela Winkler Tew, Center for Health Care StrategiesName, Org & TitleKamala Allen - Vice President, Program Operations and Director, Child Health Quality, Center for Health Care Strategies (CHCS)Melissa Bailey - Senior Fellow at CHCSPamela Winkler Tew - Senior Program Officer, CHCSComments on EPSDT and California in general:Melissa Bailey: Worked in Vermont. The majority of career was spent in child and family health (mental health) Integration and collaboration, CW, MH, Substance Abuse, developmental disability areas, to take an intergenerational approach to address children’s outcomes and their families. Also worked a lot on payment reform to change the system to be more preventive and be more upstream. Created a value-based payment system for children’s MH and CW and other child serving systems. Shift system to be less reactionary and more preventive Questions relating to EPSDT entitlementLaurie Kappe: What does EPSDT entitlement guarantee for children and youth? Do you see opportunities for supporting both clinical and non-clinical interventions for trauma?Melissa: Regular screening through recommendations or medically necessary services beginning with screening for developmental or other issues - screening to identify whether deeper assessment is needed to determine if intervention is needed.Trauma could manifest itself as a mental health diagnosis. Understanding what the symptoms are and what the appropriate treatment is, is very important.Stable housing could also mitigate trauma, but wouldn’t be a Medicaid treatment.EPSDT plays a strong role in screening and a growing understanding of the impact on the child of the parent’s own struggles. The fact that EPSDT is broadening allowable Medicaid services, like identifying depression in a mom and offering treatment is good development. EPSDT/Medicaid, has the ability to really intervene in ways that can be very supportive but has to be partnered with other components that support a family.EPSDT services need to be coded as medically necessary. The issue would be that providers have knowledge of those services, and for people to have access to those services.Re: non-clinical interventions and auditing.A payment model that is different from a fee for service model can lend itself to providing greater flexibility but relies on the interpretation of federal and state law.There have been lawsuits that have clarified what can be paid for. Flexible payment models are best options to get to more preventive options.Laurie: What does responding to trauma look like from the perspective of prevention and early intervention How do we know how to identify and when to interveneWhat are models and funding sourcesMelissa: In order to bill Medicaid, you have to have a service that’s approved based on identified needs. Programs are made up of many services provided to a family. “XYZ program” may have clinical intervention like trauma focused CBT, case management, psychotropic medication - those three things can make up a program, and the services can be billed to Medicaid or they can be provided separately as needed. Flexibility lies in the right combination of services. All the feds require is that services are in the state plan or through a waiver (or foe EPSDT in the Social Security act). Services may look different: more or less intensive. In each state plan, there is flexibility to do that. States just have to take advantage of the flexibility but some of that is dependent on the state’s interpretationRe: recommendations for California…Pamela Tew: The reason we worked closely with Dana was providing TA with CDSS and DHCS of implementation of TFC. We found in that process that the county administered system, it varied dramatically across the state where counties are in leveraging EPSDT or Medicaid. Melissa: Reticent to make broad strokes recommendations because unsure of picture in California. Can mention that the surgeon general’s focus on trauma is a very positive development. Finding ways to integrate services better so that Behavioral Health and Child Welfare don’t have “us and them” mentality is best. Finding ways to tap into nontraditional therapies is important. But “can’t treat our way out of this” because it all has to do with education, employment services and support for jobs with livable wages, criminal justice structures, etc. Basically social policies that support people as wellTrauma focused CBT, brain mapping, understanding brain development… important factors in improving outcomes.State should capitalize on opportunities to build resiliency. Pamela: TA Network for Children’s behavioral health - does TA in many states around children’s system of care. Can connect with someone that may be more familiar with California.Re: Performance Based System of CareMelissa: Vermont had a Performance-Based System of Care, created more of a global budget that started with children’s programs and expanded to adults. Vermont focused on measurements, and built its value based payment, that looked at population level measures. Things like rates of custody - did those go down? Looked at CANS measures - to begin to see whether kids’ outcomes changed over time. Was not just about counting things, but about doing those services well and producing positive outcomes. Looked at number of Vermont families with one or more children experiencing homelessness. Looked at children experimenting with drugs and less number of children experiencing self harm.Also measured engagement with services within five business days and families’ assessment of services.New Jersey has done interesting work in their system of care.PBSC is very possible. Just a matter of getting the right people around the table and making those changes.A suggestion for CA given its size: Create opportunities for county-wide pilots.Veenu Aulakh, Center for Care InnovationsNameVeenu AulakhOrg & TitlePresident, Center for Care InnovationsQuestions for All Interviewees:As we begin screening with PEARLS how must we transform pediatric practices to meet the needs of children as identified through screening/assessment?Once a child is screened, how do we proceed to know what intervention would be appropriate for a child with signs of stress? What’s going to be the warm handoff?Veenu Aulakh: So much of the support services are super local, that is part of the challenge. Once people are screened and identified with high ACES scores or have needs around resilience. It depends so much on what community you are in. Some communities have parenting support, classes, some communities don’t have anything.Putting together a generic list of programs might not be helpfulFutures Without Violence has created educational resourcesIn terms of the “What do you do” when you have high-ACES scores, so much variability, some people have access to interventions. Some communities don’t even have child psychologist are available. Its an area that is ripe for more resources. The evidence around what really works is still a bit unclear. Some have been studied more. it is financially really hard to get in place and sustain without a lot of grant support.Not sure what the plan is to bring some of the resources we do know work into a community when the financial resources aren't thereWhat we are finding: every clinic under Resilient Beginnings, they are sharing ideas, but that doesn’t translate to having the resources for supporting patients when they have identified ACES. Some have the resources to do that some don't. Need to connect to community based resources to get the lay of the land and understand what is there.Sometimes it's an association of schools, sometimes its young kids, First 5, some parents targeted. Need to explore what is in the community first.Laurie: in some ways Resilient Beginning is the beta test for some of this work. You are representing many sites.Veenu: 7 separate organizations, many of the orgs have multiple sites. All care for Medicaid and uninsured populations.Laurie: with Resilient Beginnings Collaborative. You are educating pediatricians. Understanding ACES/PEARLS, how can pediatricians who are used to physical health learn the new tools and training to be more on board with this work?Veenu: when we started the collaborative in June 2018, the legislation AB 340 wasn’t a thing yet. So this collaborative was a 2-year collaborative specifically addressing child adversity in pediatric care settings. Only in the Bay Area. The focus is around a few things, strengthening organizational capacity, building on organization led initiatives (i.e. team-based care, medical homes), sharing what is coming out of this with the broader field. We used the PICC framework (Pediatric Innovative Care Collaborative) out of Johns Hopkins. Strengthening the office environment to be more trauma-sensitive supportive, whole health, building relationships with communities. Engaging families, addressing health and coordinating services. Was never couched as a screening collaborative. We as a group didn’t make it about screening, we did not recommend a specific tools. Lots of ways to address trauma. Some orgs recognized that all of their patients were suffering from trauma, no need to screen. They focused on resilience building. If they introduced a resilience survey that was the direction that they wanted to go. At the time the lever around the new legislation was not in place. For us we said how are you going to create a trauma informed org and the ability to address adversity. The majority of orgs are screening but not all of them.Most have moved to the PEARLS screenOne organization is choosing not to do PEARLS but focusing on a resilience assessmentThe Whole Child Assessment was considered but not being usedThere is reimbursement tied to the PEARLS toolJust to clarify wasn’t entirely about screening.Have you talked to folks from the Center for Youth Wellness?Laurie: are there learnings you can share that we could include in this paper?Veenu: early lessons that we’ve learned:Part of the program required that all orgs have some sort of trauma informed training for everyone in the org (everyone from the janitors to the CEOs). Although there was initial resistance now its recognized as instrumental and they’re even asking for more training. Recognizing how having that same language, building on the same orientation has built excitement around this work. It’s not insignificant, it's been important.Data-collection. We’ve been trying to pull all of that. We have an external evaluator looking at the data, what are the tools/outcomes we can measure. What is realistic to actually get people to do? We just finished a mid-point of the evaluation.Center For Community Health EvaluationSame used as Center for Youth WellnessThe best person to speak with would be Lisa Schafer or Maggie JonesThey did some thinking at the beginning of the assessment as wellYou also need to recognize once you collect the info and the screening tool how do you organize that data, where does that information go so that everyone who should know knows about it (i.e. primary care, behavioral health, and other team members). Across the state there are multiple EMR systems and can be difficult to know how to build the right templates and ways to store the data in EMRs. It's been a challenge that people have been working on. The reality of having to pivot from one tool to another has been a challenge. Need IT support and agreement on the workflow standardization. Getting the training, how do you raise awareness, how do you deliver trauma informed care? That’s one aspect of the training. Not inducing trauma. But also there is a focus on learning about communication approaches about how you actually ask those questions. What is the best way you could administer that. So that its optional, part of our universal education. Some lessons learned about the best way to actually administer that. I think one of the actually things to administer that.Fear about what if they identify high indicators of ACES etc.However most orgs are getting lower rates of positive screens.Similar low rates of positive ACES at Montefiore and Cherokee Health Systems in Tennessee, so it sometimes takes a while for people to trust the health system. That’s just going to be the reality for when we start this. And we need to get better at how to ask the questions and support patients.Might be surprising to see how many negative screens.Laurie: so an issue with not self-reporting. Also concerns with pediatricians being mandated reporters.Veenu: we’ve learned a lot with the Montefiore experienceOne thing to address this, at the end of the day its the providers clinical judgement that is most important, it's up to them to determine what steps to takeIt's a screening tool. It's not perfect, its counter to your clinical judgement then its most important to use that.Laurie: I know lots of people are learning about this, so good to hear you are talking with Ken Epstein, and other people.Veenu: Ken is our coach on the project. Trauma Transformed did the initial trainings.Our presentation is for GenentechMegan will be presenting to NCG.We also have our mid-initiative evaluation results. I’ll see if we can share some of this with you as well.Laurie: say I’m in not in a resource-rich country. I’m in a small county, a trauma-informed pediatrician, faced with these screens that may have positive indicators, and there might not be child psychologist or supports at all. High rates of SUD, things that come with ACES. Some people I’ve talked to are very concerned about this. What is the solution if there’s asthma or something that is linked to a domestic violence situation. Are all the sites your working with experiencing this?Veenu: they are definitely not in resource rich communities. Ravenswood is in East Palo Alto for instance, very limited, not much behavioral health. Some are looking at resilience more broadly. Referring people to parks and rec. type programs. Build resilience with kids, giving out more healthy community type tools they can build on. Not going to address situations with the most complex patients. Many require true mental health resources that are limited. A lot can be done on resilience building a peer support (e.g. for new moms). When we started people said, there’s nothing in the community, now people are starting to find the things that are out there, even if it's not that many. Still a lot of unmet needs.Laurie: I am intrigued by having this large level of data available. In terms of equity it shouldn’t be dependent on your zip code for you to get support and services.We are looking to put together an inventory of age appropriate interventions and services?Veenu: it's not insignificant for orgs to make some of these changes. Need to have leadership buy-in. How does it tie into strategy? Not just the money through the screens. How do you do something new when everyone is stretched. Getting it into the EMR programs. Lots of burnout, dealing with trauma is not easy. How do you deal with the impact on staff and organizations really ready to create the trauma informed care environment.Sheila Boxley, the CAP Center/Strategies 2.0NameSheila BoxleyOrg & TitlePresident & CEO, the Child Abuse Prevention Center/Strategies 2.0Questions for All Interviewees:Laurie Kappe: Anything that stood out to you from Part 1 that you felt was important from your perspective?Sheila Boxley:Was well done, and glad to see included thinWas glad to see a nod to primary prevention, the least funded but most effective approach of all. Trying to mitigate that and really prevent itLooking at the shift in CA from possibly no having the prevention funds under IV-E waiverUnderstanding FFPSA is not primary prevention, we need to look at this as a state and a nation.Laurie: Learned that there is going to be some additional funding to build up the evidence based clearinghouse under FFPSA, and more IV-B money.What would you say is the cautious win out of this potential rule change/legislation?Sheila: it’s still in play, hasn’t officially happened yet? It’s not a done deal yet. I believe it is critical that at least in the short term we have some resolution to the short term waiver and the $320 million for prevention. But there isn’t another funding stream of the same level that is specific to primary prevention. Laurie: nothing is going to match what we were able to do with the waiver.Sheila: the extension is really leaning into the implementation of FFPSA, probably in 2021 in California. FFPSA isn’t really about early-intervention, but not really that early. Lots of debate about candidacy. Only those in imminent risk of entering child welfare, that’s pretty far down the road.Have to keep our eye on primary prevention so we have fewer of those folks coming.Laurie: so once we screen what do we do? Once we assess then what do we do based on ages and stages of a child’s development?Any assessment tools or particular interventions.Sheila: a lot of tools and a lot of them are valid. What they lead to in terms of how the respond,We are still grappling with thatNot there with generalized agreement in terms of assessing individualsDo we have assets and the structures in place so that we can respond to that information.Not going to be that successful if we don’t have the systems in place to respond.We know that we have assets around the state, depends on if we have newborn or a teenWe have about 500 Family resource centers across the stateWe have documented this in a variety of casesThey are well liked organizations, trusted in the communityThey are either the providers or they can get people where they need to beThe simple notion of guiding people is not always very effectiveBut a resource that looks at the whole family and the whole child.Laurie: I am trying to understand, is there a website, a good description, who at the state person to quote Sheila: the CA family resource association who has a new director I can connect you with.The Governor signed our legislation to put family resource centers into statuteSo there is now a legal definition of FRCsWe’ve been doing a listening tour for about a year and a halfGoing to individual FRCs and networksHaving conversations about needs, trends, etc.There are no more dedicated people than those individuals that are working deeply in the community. They are change agents.Laurie: How do these family resource centers get financed?Sheila: financing is incredibly limited, it's like trying to use duct-tape to keep everything together, no dedicated funding stream. In effect they are funding from a whole variety of ways, First 5 has been important. But that is a declining resources, declining at about 2.5% a year. Some have been funded through IV-E waiver process. It may be SAMHSA, public health, workforce development, a whole array of the variety of services families need, they really need core infrastructure funding. That funding doesn't work in silos. So the funding is precarious, and if there is another recession then these kinds of services are the easiest to cut since they are not mandated.The first year the IV-E year waiver was supporting FRCs in SacramentoThe 1.4 Million dollar investment the county saved 6+ Million in a year.Are you familiar with the Packard report, and vehicles for change.Laurie: What should we be measuring, what should we look for in terms of data? E.g., mental and physical health indicators, educational outcomes, others? Right now we’re doing penetration rates etc.Sheila: let me say several things, when you’re looking at primary prevention, you are looking at the absence of negative outcomes. BC you can’t promise that a person is going to fall off the cliff, there have been a number of evaluations that have looked at some specific kinds of outcomes. Frankly from prevention it would be social determinants of health, there have been evaluations of prevention and early intervention programs, they have been in specific locations and are limited in scopeOne network did family visitation, and they looked at families in their program 175% less likely to enter child welfare vs. the control groupAbout 1,000 cost for that family in successVs. 278K per child welfare caseThat was a CA based study.There is also some interesting work going on in Orange County that is in process. There are also for a period of time the Family Development Matrix, there was one tool used by prevention programs that did have good results.The prevention centers were the In prevention, it's hard to track people over a longLaurie: like the Perry preschoolSheila: there are also the families that we’ve learned from that are community leaders and providers.Triple P has some good outcomesThere are a number of performance indicators, but again it depends on the level of impact and level of time you can track.In terms of prevention, once everything is stabilized they don’t need to report back and keep in touch.Laurie: with the screening, I am intrigued by the data-linkage possibilities, coming up with some sort of evidence-based we haven’t had before.Laurie: how does this organization and the listening tour all work?Sheila: the CAP center is the umbrella organization for several programs:Prevent Child Abuse CA (State chapter of prevnt child abuse america)We do America and Vista through thisThe CA Family Resource Center AssociationStrategies 2.0 the family strengthening providersThe Local Child Abuse Prevention Council for SACAnd a 501.C4 which allows us to do lobbying.We do everything from advocacy to training, to direct prevention.We have private funding, public funding, donations, and some fee for service.There is once CEO/President and board of directors for the entire agencies.What would a performance-based system look like-- are there any models you think we should be aware of?Are there counties in California you think are on the right track in doing this work?Laurie: is there a local agency person, county person, that would be a good on the ground perspective person to interview:Ron Brown, the CEO of the Children’s Bureau, his organization and ours are partners in Strategies 2.0Sheila: one of the things you might have heard about CWDA has the prevention cabinet, and the office of CW prevention under CDSSPartnered to do a summit in Jan/Feb22 counties to do cross-child abuse preventionBoth OCAP and Strategies 2.0 is doing consulting work in 25 countiesA lot of active planningEach time had a CW director, First 5 director, family resource center, and representatives from education and health where there.Only work for 10 people from each county to comeWorked out differently by countyLaurie: would love from a distribution perspective, if you have an email database that you might be able to share so we can send them to the various teams from the 22-25 counties.Laurie: Anything else we should know about? Final commentsSheila: only that we will undoubtedly know more about the IV-E waiver extension later this year, but not something for today. Not sure the funding levels, but its 90% of the dollars in this fiscal year and 75% the following year, that’s what has been proposed.Jeremy Cantor, JSINameJeremy CantorOrg & TitleJeremy: Senior Consultant, JSI San FranciscoLaurie Kappe: we are interested in both the measurement evaluation piece and the intervention piece.Jeremy Cantor:JSI is investigating three primary questions and one secondary:The state of language, the questions about what is a glossary of terms in use, understanding meanings, our take on that, how do we get beyond the glossary. Where is this showing up? What resonates with whom?The second is around interventions, now that we’re gonna invest a huge amount of money/resources/time, then what? What do we know about what works, Though I also think there is a parallel which relates to what works in which sectors, what are the roles in different sectors, differentiating between individually focused approaches, and organization systems and policies. How do we bridge/connect the mitigation and response strategies to prevention strategies.The third is how are we measuring impact, that is the piece we are trying to sort out. We are trying to figure out what the right niche for us to play. A lot of discussion around some of the specific approaches and investments, such as screening, and like with a performance based system, how are we going to measure performance? How are we going to get beyond tracking the number of people screened, referrals made, etc.What are the outcomes we are going to record and create accountability aroundThere’s a research questions, and all the folks have different measurements, How do we create order, priorities, some translation across, getting a more coherent sense of measurement.Of the three this is the one we are the least certain about. We are trying to be sensitive to where the opportunity is in a fast moving landscape. Is this a research project or should we focus more on convening the entities that are going to have a voice in shaping the policy, what is our role?SUB QUESTIONCross sectoral piece, the interventions. Specific to the health sector at all, not clear that we have good models for how collaboration can happen across sectors.Laurie: so tell me what your work product is going to be, are you going to have anything that you would feel comfortable providing me in the next few weeks?The pediatric world, there is probably going to be some trepidation about administering this screen. It is self-reported, but pediatricians are mandated reporters, and they might see their role as more physical health, and not so much behavioral, or helping with housing supports.Is that part of what you’re looking into?Jeremy: To some extent, but we are not interviewing clinicians.What scares me and others: we are rolling this [screening] piece out fully scaled but without scaling the other components. My sense is that the clinician resistance is about that, clinicians are problem solvers, will they have the resources to solve these problemsAlso staff concerns, what about staff wellbeing, will they be re-traumatized?How do you build a full-fledged response when systems are going to have to respond to this.This is a place where we can contribute in terms of a literature scan and review, that will be one piece. I would be happy to craft a quote that aligns with what you are trying to communicate. Two other things that come to mind: In the language space, narrow piece, Erin did a scan of terminology and a lot of the same terms and where they are showing up in state policy.We could shoot those over to you so you could take a lookWhat is the difference when you say adverse childhood experience vs. resilience vs. toxic stress.When you say ACES clinicians and researchers say ACES, its quantifiable, but unless it’s aggregated you can’t look at it from a prevention standpointThere are concerns about stigmatizationWhat are the strategies behind that.Laurie: would love to see that. Some understand trauma as only physical, need the behavioral health aspect.Jeremy: we’ve been kind of kicking this around in terms of what we can include. If there is a short table or graphic that we could check out. Now that you have the terms where do they lead you? We don’t have all of that packaged up, but there’s probably a piece of it we could put together.Laurie: Want to have all the interviews and research done by Oct 15th, and then we are drafting. If you get it to me before the third week of October that would be really helpful. In Part 1 we inserted the trauma-transformed chart and then gave Jen a quote. We could do something like that, credit you and give you a state.Jeremy: I’m a public health person. I think Erin would describe herself like that as well.We don’t have a deep history of working on child welfare issues per seWe’ve always had some emphasis on children’s health and well-being.Whether it's childhood adversity or diabetes, how do we create functional collaboratives that are based on shared outcomes and coordinated strategy.it's almost like applying a health in all policies type framework, it's kind of like a children in all policies. How do you view the implications of what you're doing. Should kindergarten readiness be a Medi-Cal pay for performance measure?There are ways to insert metrics across sectors.When you look at different metric sets from different sectors there is some alignment, you can start to do a crosswalk, there are four areas of measurement that are shared, but can you actually share them? The base, the root issue has something to do with educational readiness, so that’s one, others might have to do with family stability, etc.Laurie: What would a dashboard look like?In child welfare we have a somewhat performance based system, we look at time to reentry, permanency, reunification, etc. We measure our system on all of these measures. We have all these measures, but we don’t have measures that integrate behavioral health into this. So much of it is at the school-based level.Jeremy: thinking about this. What might this actually look like. What is compelling/communicable. So there might be something there. We can get back to you once we’ve had some time to think about this.Dominic Cappello and Katherine Ortega Courtney, Anna, Age Eight InstituteNameDominic Cappello, Katherine Ortega CourtneyOrg & TitleCo-directors - Anna, Age Eight Institute at Northern New Mexico CollegeLaurie Kappe: What is the state system in New Mexico doing to respond to trauma and toxic stress exposure for their child welfare population?Dominic Cappello: We’d talk about three categories, trauma informed, trauma sensitive, and thirdly what is their capacity to actually implement strategies, that could get us to become a trauma-free state. Nationally the term trauma-informed is used a lot now, that's the first step, but we are very committed to moving far beyond that, to look at the actual steps a county needs to put in place the services that actually prevent this from happening in the first place.We work with our data leaders program not only in New Mexico, but Pennsylvania, New York City and Connecticut.We could talk about in terms of where they’re at trauma-informed, and where they’re actually at capacity wise to start to implement the work.Laurie: what you are talking about is how do you get to a performance based system where you are actually practicing.Katherine Courtney: we are just starting (officially launched July 1st), we are working with 3 counties in New Mexico and possibly one Pueblo. These counties invited us so they already understand that this is an issue and wanted to address this. The disparity in terms of understanding and desire to do stuff varies greatly in New Mexico (similar to California). From a school perspective, it's almost teacher to teacher.Dominic: our lens is different than most people’s, over the last 20 years (since ACEs study) it's been from the perspective of psychology, and our lens is the social determinants of health. AKA health disparities, educational disparities, opportunity disparities.A lot of people nationally are coming from a psychology point of view, while we include that we have to communicate with people from a different lens.From the three counties we are working with (in New Mexico) one of the counties actually took off right after we published the book.They read the book, understood the 10 points, and said “why don’t we start now”We didn’t have the infrastructure, this was before the instituteShe got leaders from agencies (gov and non-gov)Because she was a city council person she has a lot of cacheThey said they wanted to learn about continuous quality improvementWanted to understand adaptive leadership, collective impact modelThey haven’t lost any steam.We are going to the next phase; deeper instructionFor us to start work with any county we start with the Resiliency Determinants survey (its in the survey)So the survey was expanded by New Mexico State UniversityShould have results in about 1 ? months, the survey is going to be done onlineWe are going to have a map of the county and do data analysis, and assessment to see where the gaps are and identify potential solutions (through data-mapping).Laurie: so we’re going to have in CA a potentially incredible database, 5 millions kids and their information. We can cross-tabulate data, have a zip code level, look at all these social demographics. But what do we do next?Dominic: we have a 100% community initiative, the ability to build the resources county by county, so we would say to you once you get 5 mil identified you’d break it down by county. So we’d start with, who are the council members, the COE, the people we need to get buy in, the community leaders. But that long term work with county leaders working to build the system, that’s where we’re looking to go.Laurie: so you’re familiar with the results based accountability model (Mark Freidman), so we want to look at this and say OK what’s working and what's not working. We have a financing model that doesn’t let us do anything until there’s a diagnosis. So we’ve had EPSDT forever but we don’t really use it to prevention. We primarily use it for clinical, even though non-clinical is many times more effective. So wouldn’t it be something if we actually had an agreed upon goal, so saying in 5 years, x fewer kids have x fewer aces, that would be something we could measure.Dominic: so I would say if you do the resilient communities survey in counties, you could watch those gaps get smaller. So in 10 years, maybe you could get 100% of families able to access. Make it measurable and meaningful.So ACES survey plus resources surveys need to be done togetherHaving the 2 is a powerful double punch.It's on our website.Laurie: so in New Mexico, I’m getting a better sense of where your vision is, and I’m curious about the results of your survey. Dominic: we should have results in about 6 weeks. Right now just the pilot communities.Laurie: with the implications of FFPSA and the necessity of having evidence-based, or well-supported, promising practices, a bar is set that can be difficult to reach. What are the policies, programs, that are well-supported that are being used in New Mexico?Dominic: there is evidence around things like reducing food-insecurity. So this went well with lawmakers 5 services for thriving 5 for everyday needs, there weren’t many questions about those:Food servicesStable housingTransportationBehavioral healthcareMedical careSo we didn’t have to defend those. So they were saying, you sure those don’t exist, and then we did the services. So if you’re doing this in the schools, there is so much evidence that a normal school with behavioral healthcare creates huge benefits, tons of evidence base.Home visitation: tons of evidenceEarly childhood learning:Youth mentors: that’s why we needed itJob placement and training: we are part of a college, every college and university is communicating about this research.So 5 are no brainers and the other 5 have decades of research behind them. We included things like child care, making sure it doesn’t stop in the summer.Laurie: so the other rules that are coming from the feds, making it hard to have services available for these families.Dominic: our belief, we’ve been looking at city budgets, higher education budgets, we look at cities, even small cities, not well resourced, we still see a lot of money out there. Where does this money go? We are trying to talk to the communities about where this money is going. So we talk to mayors and we talk to communities and they say we agree with you but we don’t necessarily see that as our role.We always hear “city government isn’t really set up to do that”We are having our biggest breakthroughs in Do?a Ana countySo when you lose your job, and your middle class family suddenly those services become really important.Laurie: so for your model, you are looking at perhaps bigger picture. So you’re not necessarily just looking at kids going into child welfare and trying to reunify, and trying to prevent a lot of that trauma.Katherine: in New Mexico we’ve had a really dramatic increase for kids going into care. We are really focused on preventing that in the first place. Some kids get out quickly, but others get stuck for a long time, they’re really traumatized and have complicated cases.We want to try to prevent/intervene really early, prenatally.Dominic: the reason we got funded, a state senator gave the ACEs survey to an AP Psych class, and he discovered ? of his students had at least 3 or more, and many had a high level of ACEs. And the students actually asked him, do adults know what is actually happening to us? And that was enough for him to develop a bipartisan bill to support this. We worked, Katherine and I with child welfare, we know the challenges they’re facing, worked social welfare departments. And we know there are many in New Mexico and nationally, that are on the verge of entering child welfare, and we know that they may never get services.Laurie: With differing levels of trauma/dysfunction, how do we heal the family enough to reunify, and how do you actually reunify?Dominic: so you have to build up the 10 sectors, so we need access to these services, without behavioral healthcare, without housing, etc. Some people ask, can we reduce it to 5, we need all 10. American’s sometimes want 1 or 2 things, but it's more complex. Once you get to the research of the social determinants of health. We hear you, we hear about what your article is trying to do.When we talk to Taos Pueblo we have to get these 10 things in place to even start to have forums on historical trauma.Laurie: I’m envisioning a page in the paper, something along the lines of “a more expansive vision”.Dominic: as you can see from our conversation, what you’ve heard, while child welfare is a critical player in this work, they are just one of many. So we’re looking at 10 different sectors, and 10 state departments. So we are asking them to think big picture, and in defense of child welfare it can’t all be loaded on their shoulders. When you get to the chapter on child welfare, it's time to share this responsibility, we need to get behind them and support them. ACEs research tells us the problem is a lot bigger than we think. And we have the tools now, we have the tools, the technology, and we need the political will at the county level. Even if the state leaders want it the money could go into the counties and nothing could happen. We chose a county model very strategically, you combine the city budget with the school budget, and Our key framework is continuous quality improvement. The county is always evaluating, a non-stop loop.Kanwarpal Dhaliwal, RYSE CenterNameKanwarpal DhaliwalOrg & TitleCo-founder and Associate Director, RYSE CenterQuestions for All Interviewees:Laurie Kappe: What programs do you know of that work to mitigate trauma and promote healing across different ages and stages? (Not just programs in California).Kanwarpal Dhaliwal: in terms of programs and orgs. I think about Young Women’s Freedom Center, CURJ (Communities United for Restorative Justice), Fathers and Families (San Joaquin). Those are the three that really come to mind.They are doing work as culturally responsive, healing centered, social and emotional learning, that includes socio-political development, responsive frame: what healing is about for so many communities. More in tune with the definition of healing with those communities.Laurie: So a lot of programs in late adolescence. What is the age cohort at RYSE?Kanwarpal: right now the age range is 13-21, but some programs and supports, our hospital-link program, go up to 24, but in real life, we’ve supported people up to the age of 30.With individual youth, we do family-based counseling, services that extend beyond the youth themselves.When we open the new facility it will be 11-24.And we’ll also do family based programs.Laurie: what are the key things you want our target audience to know about why RYSE is an effective program?Kanwarpal: I shared this in the previous interview, what we heard in the planning for RYSE, in the organizing, what we continue to hear: is that young people feel like they need and want space and opportunities to engage with each other, deeper relationship building, also with adults, in order to be able to grieve, heal, and build collective power to shift and shape broader conditions of distress. Tend to What’s happening on the ground in real time and to the What are the root causes.How do we shine a light on the causes of what is happening to them with the systems in power.Young people want to be connected to the systems that are responsible for them.Sometimes we are aligned sometimes we are not.We are committed to being in a partnership, these systems are responsible for our communities.Laurie: we’re hoping to talk to youth from your program, ideally someone with some system involvement.Kanwarpal: we can work with you on that. Better to hear from them than hear for me.Laurie: What would a performance-based system look like-- are there any models you think we should be aware of?Right now we’re just measuring the number of mental health visits, we’re not measuring results: changes, healing etc. From your perspective what are your perspectives on what programs are actually effective in mitigating and preventing the effects of trauma? So its schools, mental health, community orgs, shared responsibility.Kanwarpal: We feel like the outcomes that we’ve developed and the metrics as an organization fall into two domains. This comes from our theory of liberation that we created in our last impact planning process, so that its (1) young people feel loved and (2) that systems are transformed to love young people.So from a systems side, if there is a system involving young people, they should be involved in the decision making.There should be no policy or system that’s created that does not involve children of color, and young people that are affected need to be involved in evaluating, designing and implementing these programs.Should show community and love to the young people they are in service to.Those who are affecting and stewarding the system need to be loved and be held by the system.Laurie: not to be cynical, but if someone were to walk into a child welfare meeting and say “do you feel loved” it’s hard for me to imagine that. But it is a powerful idea.Kanwarpal: there are ways to ask and inquire, and is the system ready to hear what the responses are?We do an annual member survey, and we ask do you feel loved at RYSE? For instance we ask our staff: do you feel loved at RYSE, do you think the staff love each other?We used to ask different questions.There are ways to ask with different dimensions of thatYoung people keep saying we need to feel loved. Not out of the ballpark for what systems need to be doing.I know what the reality is but if we didn't start saying what needs to happen, it's just going to continue to be the same systems mediocrity and blandness at beLaurie: beyond the self-reporting surveys, are there other metrics that should be included, proxies? For example:When we first implemented first 5 we had proxy indicators to see if kids were ready for Kindergarten, we came up with whether the kid had been to the dentist?Is there some similar way to measure that impact?Kanwarpal: I would say, instead of measuring school readiness, I would want to know how are the schools ready for young people, for students wherever they are. I think that’s the shift, so what’s the measure or proxy for that? Can they hold what young people are feeling? Are they hiring from the community? Do staff feel trained, confident, do they have support from leadership? Not so much “are the students ready?” That assumes that schools are the baseline, doesn’t mean the school has to do anything, not what they can do, but what the individual and the family can do.Laurie: the performance-based indicator must be on institutional readiness and competence.Questions on financing:Laurie: What is RYSE’s financing model? So were looking at what is a “promising program,” how do we support programs like yours? What recommendations do you have overall for financing healing systems?Kanwarpal: Organizationally, our funding streams, about 40% county health services, MHSA (Prop 63) dollars, 40-45% foundation and philanthropy. Some funding from the state, some funding from the feds.We have 60 different funding sources just for RYSE, not just the RYSE commonsIt's actually about the relationships, we are in meaningful relationships with all of our partners.The resources that we get in our funding, that money is not the states’ money, not the foundations’ money, it’s our young people’s money.We understand that they are stewards of that money and there are things you have to do.We really look at it from a reparations framework.Within a capitalist model that’s the assumption. We have relationships, we expect and enter them as partnerships with mutuality.That’s the piece around it, that's the mindset, those dollars are our dollars. When we understand that, then how we understand our work it's a different way of being.It’s also constantly on our minds, there is not a minute that goes by, that I know that those of us who have more responsibility in this area aren’t thinking about it. But also making the connection between different funding streams.There are different frameworks/value sets, some funding sources are compartmentalized, but we go in there and say this is our values. If the funding stream does not support our values then sometimes we have to say no-thank. We had workforce investment dollars, but after a year it was only transaction-based, not relational, it was getting in the way of what they said they needed from us. So we said ok lets just collegially end this contract.Laurie: so for our recommendations for this issue now, elevating promising programs, thinking through a performance-based system, financing, etc.Kanwarpal: I would question and push back on what does it mean to be performance-based, more to me: what is the culture shift that has to happen, that’s the measure I would want.Performance-based still upholds a notion of productivity and deliverables, an economic frame, a capitalist frame.I would rather see a relational based I don’t want to produce more diagnoses to get moneyI don’t need to do a diagnosis, trauma is atmospheric, because I know that white supremacy is the problem.Shifting on every level.Shifting the behavior change to be on systems and not on individuals.Need to be responsive to what are the meaningful metrics for communities.What are meaningful metrics, that's what we should be measured on?Laurie: Anything else you think we should include or consider?Kanwarpal: It will be good for you to talk to a young person.Joyce Dorado, UCSF HEARTSNameJoyce DoradoOrg & TitleCo-Founder and Director of UCSF Healthy Environments and Response to Trauma in Schools (HEARTS)Questions for this issueLaurie: Once a child is screened, how do we proceed to know what intervention would be appropriate for a child with signs of stress?What are some promising well-supported evidence based programs (both clinical and nonclinical)?What measures might we use to measure success?Joyce Dorado: Thinks it is great to try to screen for ACEs in kids in primary care. It’s a good idea. As long as primary care clinics are prepared to respond to children with ACEs in a healing-centered way (as opposed to a pathologizing way).PEARLs is what people have settled on - and it leaves out pretty important stressors, in terms of community level ACEs. When we think of what adversities children are up against, these include poverty, community violence, racism. (actually, I looked at PEARLS and it looks like it does include discrimination, community violence, and other community level adversities [])Based on research conducted in Philadelphia by Cronholm (2015 study that looked at community level ACES: witnessing community violence, poverty, experiencing discrimination, foster care). Helped widen the lens from original Kaiser ACEs.What we assess for will be what we intervene around. If we only assess for individual ACEs, we miss the bigger picture of community level trauma that many of our families are up against.When we screen for the broader set of ACEs, we find that some communities (e.g. under-resourced communities of color) are disproportionately affected. Anything that deals with ACEs needs to be addressing for systemic wide problems like racism (i.e. structural racism—not only historical racism but present-day institutionalized and every day racism). When community-level ACEs are not considered, the disproportionate burden of adversity that systematically oppressed and marginalized communities are up against remains invisible—and therefore these adversities and the resulting toxic effects often go unaddressed.Laurie: This begs questions “What can social workers, clinicians, policy makers, possibly do about such large problems like racism and discrimination?”Joyce:On an individual level, service providers can help clients counteract messages that makes them think “there’s something wrong with me” when it’s the system that is wrong (i.e. when they are having an understandable response to a harmful system). There’s a lot of good evidence-based practice on trauma that could help counteract these systemic issues.Responses include using trauma-informed approaches as long as it includes how discrimination is part of the problem. There are replicable, well-established curricula that exist around anti-racist work. For example, “courageous conversations.”Experts in this field such as Dr. Kenneth V. Hardy are writing and speaking about ways to heal the wounds of racial trauma (e.g. ) and approaches for talking effectively about race (that anyone can do) so that we can begin to address racism in our interactions with each other () Also important to focus on talking to young people about what it is they need (i.e. bringing in the voice of young people rather than assuming what they need—doing things with them, not just to them or for them)Important to talk with people who are proximate to the challenges of working in trauma-impacted school communities. RYSE (in Richmond) for example is currently doing a listening campaign with educators (they also did a listening campaign with youth).Another good resource is the National Child Traumatic Stress Network. They have a “Trauma Treatments” list. Includes evidence behind them.There are evidence based interventions like TF-CBT, CBITS. These are good and they are not yet sufficient to address the kind of chronic complex trauma that kids are exposed to. These treatments were originally designed for PTSD, and that is a very specific disorder. Not yet at a point where it can treat the intense dysregulation that children experience, and not at a point where they can address ongoing trauma (i.e. when folks are not post-trauma)If we only focus on PTSD and the treatments that address that, we miss the boat in terms of addressing complex trauma, early chronic trauma that usually happens within context of caregiving system. The way that it affects kids is much wider and more chronic than PTSD captures. PTSD doesn’t capture range of difficulties that children experience. There is a whole body of research and lit. around complex trauma - interventions that come out of that include Attachment, Self-Regulation, and Competency Framework (ARC) (Kristine Kinniburgh)TARGET (Julian Ford) - focused on JJ systemContinued focus for this field is to make sure it addresses collective level trauma. Like xenophobia, racism.Chris Blodgett at CLEAR (Washington State University) has done research around how ACEs affect learning and what can be done in schools.Systems level actionMake sure we provide trauma specific, culturally responsive clinical interventions for kids. That involve the adults that care for them and their families, Including the other professionals in the kids’ lives, like teachers.The ACE score should also not be used to pathologize the child in the primary care setting where the PEARLs assessment is used.How are organizations looking at their own policies and practices to ensure that they promote trauma informed approaches to healing, equity. This includes not only the practices that we do with people we serve, but also how we interact with and treat each other. It includes policies and procedures with the people we serve, but also the policies and procedures that create our working conditions.Review T2 principles. These trauma informed principles matter so that the new assessment is not used to cause more harm.Whole school approaches toward creating more safe, supportive and equitable learning and teaching environment are really critical to being able to help mitigate the effects of adverse childhood experiences and trauma, including the trauma inducing effects of racism, sexism, homophobia, xenophobia, ableism, and other forms of societal oppression (i.e. socio cultural traumas). HEARTS has principles around this, co-developed with educators. Our work is to offer a trauma-informed, culturally responsive, restorative lenses to educators and other professionals, so they can do their work well, while staying well themselves. (HEARTS principals are essentially the same as the SFDPH/Trauma Transformed principles—they co-evolved—but the HEARTS principles are specifically geared towards the educational system).We work to create shared language and shared understanding about the effects that trauma and chronic stress can have on any of us—on our health, behavior, relationship, work, and organizations, and to offer approaches and strategies to mitigate these effects that anyone can carry out, regardless of what their role is in an organization. We understand that this is not about “those traumatized people over there vs us over here,” but rather that we are all in this together. By in large we are all affected by chronic stress and trauma, and so we all have a stake in doing everything we can to address these negative effects and heal from them.As someone has said (from Trauma Transformed): If we do not transform our trauma, we are bound to transmit it.The lens around what we’re up against and what we’re doing to mitigate adversity also needs to include a cultural humility and responsiveness lens. Cultural humility is reflecting together as community around root causes of things like homophobia, racism, and holding ourselves accountable to counteract those forces.Then, asking how we are making sure to mitigate the effects of secondary traumatic stress and attending to wellness and resilience in the workforce.Next article could add a column about ACEs that were identified in Philadelphia study.Support reflection instead of reaction, curiosity in lieu of numbing, self care instead of sacrifice (from Ken Epstein et al’s paper): )Laurie: What would a performance-based system look like-- are there any models you think we should be aware of?What are we measuring, what should we look for in terms of data? E.g. educational outcomes, health indicators, short-term outcomes.Joyce: There are measures on Trauma informed systems on the T2 website. (There are further resources around creating safe, supportive, and equitable schools using trauma-informed approaches at Hearts.ucsf.edu). And trauma transformed website: policy audit tool - how do we make sure policy has trauma informed lense?There is also evaluations to see where system is in terms around trauma informed work (e.g., TIAA)It is necessary to measure not just outcomes but system operationsKen and crew have tried to capture systems change - may want to check in with them on whether it’s been successful.In schools, HEARTS has aimed to increase instructional time (e.g., decrease disciplinary office referrals, decrease suspensions), increase student engagement, increase staff wellness, increase staff retention, improved school culture (can be measured via school climate measures and measures such as the School Quality Improvement Index (SQII) CHKS). In future research we would like to disaggregate these outcomes to examine whether trauma-informed approaches (including restorative practices) can reduce disproportionality. See our paper in School Mental Health with promising data from our whole school trauma-informed approach.Dorado, J. S., Martinez, M., McArthur, L. E., & Leibovitz, T. (2016). Healthy Environments and Response to Trauma in Schools (HEARTS): A whole-school, multi-level, prevention and intervention program for creating trauma-informed, safe and supportive schools. School Mental Health, 8(1), 163-176. Here are organizational equity assessments: Dozier, University of DelawareNameMary DozierOrg & TitleProfessor, Chair in Child Development, Dept. of Psychological & Brain Sciences, University of DelawareKey information we are trying to findLaurie Kappe: Background on ABC - why should CA pediatricians, and other stakeholders, know about it?Mary Dozier:Will send Laurie Kappe a book about the intervention. Provides vignettes of evidence. Also giving a talk in CA in Dec.13ABC is 10 session program.Identified key issues experienced by children that experience adversity. When they experience adversity, they push away their parents. Makes it difficult for parents to be nurturing. Found that otherwise nurturing parents responded to these baby cues in non nurturing ways. First intervention component is to help parents recognize the need below the baby’s response. Second bit of science was seen by researcher in monkeys who dysregulated after being separated from parents. Mary found blunted patterns of cortisol production/regulation in kids from foster care. Found that when parents are well attuned to children, children develop better regulation.Third observation was that birth parents’ responses to children could be frightening. So third intervention was based on this finding.Most important thing ABC does is that coaches make comments in the moment, about 1 per minute.Parent coaches code observations/comments.Parents are hearing 60 times what they did right. They’re getting practice and hearing observations. Creates cascade of positive behaviors.Coaches vary in profession. In some places, there are parents who are parent coaches, but also clinical professionals. ABC screens potential coaches. Laurie: What role does cultural competency/humility play in parents receiving comments, respecting coach?Mary:The comments are based on real things that a parent is doing at the moment. It helps with credibility and trust. Hearing positive, real things that a parent has done is powerful and helps parents build confidence in themselves.First 3 sessions it’s all positive comments. After that, coaches would be able to suggest an action - but still not negative comments. We want parents to be the experts.Evidence: How do we know that this intervention helps heal or mitigate the effects of trauma?Have completed 4 randomized trials.One with CPS involved adult parents. Children have been evaluated up to age 10 and will study at age 13-14.ABC was studied against control focused on cognitive development.Children in ABC showed more secure attachment. (Disorganized attachment is something you want to avoid. Breakdown in strategy or not having a strategy. Child pushing parents away, child turning in circles when parent walks in. Associated with dissociative symptoms, etc.)ABC kids less disorganized attachment.In terms of cortisol - ABC makes cortisol more normal: A higher morning value, lower in the evening. Effects seen 3 years later. Also seen at 8 years of age. Inhibitory control (impulse control): ABC kids are more successful at a task that measures their impulse control (coloring something as opposed to playing with a really interesting toy).Children were given an MRI scan - results suggest a rewiring of the brain. ABC kids see more top down regulationHas also seen data that suggests more mature prefrontal cortex in ABC kids. Better autonomic regulation (heart rate).Believes parents changed and stay changed after the intervention.Laurie: What would be assessment tools that would help stakeholders understand whether a child is exhibiting symptoms of stress like dysregulation, other problems that need to be addressed?Mary:Suggests that parents be assessed of their sensitivity to their child. Code it on a 5 point scale. “If 3 or below, give them intervention.”Children so often look okay. If parents are not being sensitive, and children are living in adverse conditions, that’s especially when children need sensitive care.It was used by NICHDOther programs:Parent child intervention therapyParent child psychotherapy - LiebermanCriticism may be that intervention is too short. Also that the intervention has worked because it’s for people who don’t need it as muchNobody has challenged ABC body of evidence. Questions on financing:Laurie: How would a jurisdiction pay for this?Mary: There are places where Medicaid can pay for it. FFPSA is considering including it in clearinghouse, but not in it yet.Cost per family: 1k+. Can see 40 families a year, per coach. 10 a week.Rajni Dronamraju, GenentechNameRajni DronamrajuOrg & TitleAssociate Director, Charitable Giving at GenentechQuestions for All Interviewees:Laurie Kappe: As screening of youth and families in California is increasing, how can we as a state respond so that families are getting appropriate services?Rajni: Focus needs to be not just on screening but provider training. Doing the work towards building a care environment that is doing the work to support patients that are affected by trauma. Doing the follow-up, baseline level of service that needs to happen. Affecting the culture of the screening institutions to make sure that they’re trauma-informed. Typically that would involve the 101, 201, trauma informed type of training. Would be ideal if that were structured as incentivising and encouraging orgs. To see how they embed a trauma-informed approach from the top to bottom of the organization. From leadership all the way to the training and support that needs to be in place for the staff, as well as systems and services and things of that nature. The environment in which screening is done is critical to its ongoing success.Even if we are just thinking about medical providers alone. They are not taught about the impact of ACEs on our biology in medical school.We need to help them understand, we need to take away the fearThere is a tremendous amount of confusion, am I supposed to report this kid to CPS?Unless you do the organizational training and support in this work it's going to fall flatThere are some organizations who are doing the work to show what a trauma informed approach could look like, but a lot of that work is still emerging.There are a “sites of excellence” we are working for, Kaiser has supported some.Screening is really only one ingredient to a package of interventions and shifts that need to happen in the screening environment.I think that building on that, and I understand that this may be part of Dr. Burke-Harris’ vision, I am a firm believer that when screening is done well, and is connected to the right kinds of supports it can be transformational for families.How that kind of conversation can shift a family’s perspectiveCan create a lightbulb moment. How is this affecting me? How is this affecting my family or my children?Have to have the right system of support and care in placeHave to have the right systems of primary care and behavioral health.Other social determinants of health, connect them to clinical services and track how that’s working.Approaching it in that way, in the field that is so emergent, you have to do it with a learning mindset. Help us understand what’s working and what’s not.How do we evolve it based on different care contacts.Can’t just say, everyone go out and screen! Good luck!Need to be added training and incentives. Need to be able to do that learning and change as a state. Need to be able to be reflective of the time we are in.Some will be like “great, this is reimbursable, let's do this.” Some folks are going to be more intentional.My hope is particularly from a training perspective the rollout will be attuned to learning and thinking about what the model needs to be. The full scope of work about what a trauma-informed system of care is, not just ACEs screening.The screening is going to reflect the training of the provider administering it.Some may see it as just a way to get the 29 dollar reimbursement.Could be a resource deficient area.Not everyone has the resources that UCSF has.Laurie: I know you’re working on quality improvement. I have had several people refer to sites that have been working with the Resilient Beginnings Collaborative.Who would be my best key informant for what would be most relevant and shareable out of the work of the collaborative to date?Rajni: Veenu Aulakh, and Megan O’Brien at Center for Care Innovations. We do have a midpoint evaluation, more internal focused. We also have a freelancer who is documenting the journey from more of a journalistic perspective. They can give you insight on how we approved, how we deal with the clinics. What are the anxieties, how are they responding to the new momentum around the reimbursement. Folks overall: everyone wants to know what tools to use, which are the best.Interesting that the PEARLS one is the only one that’s being reimbursed at this point.It’s from a very specific contextIf we are thinking about this for children and adults don’t know how relevant this will be given the context.Laurie: Is there work you want us to highlight?Rajni: I think the work with Jeremy Cantor at JSI will be most pertinent for that question. And with Center for Youth Wellness, I don’t think they’ve gotten far enough with documenting to show much.Our work is mostly focused on early-childhood and anchored in a health setting.Laurie: I am curious to see if we are going to be able to anonymize the data and look at population level data. Can we look at the aggregate level for instance if there is a lot of substance use disorder in Fresno. So in the resiliency project that you are doing, have you been looking to build up the resiliency or protective factors?Rajni: The early childhood focus is largely driven by a way to think about this as prevention. And with the pediatric approach, when children are young and the number of opportunities to be in front of that child at that young age, when they get older it can be harder to get to them (when they are school-age). There is a broad movement, very aligned in terms of how to think about pediatrics in particular as a place for supporting the social and emotional wellbeing of families. The universal developmental supports, in addition to early care, that can help boost and drive connection to those protective factors, or resiliency factors. A lot in terms of how we think about the delivery of those services. In terms of being a response to some sort of severe diagnosis. This gets to what we’ve been talking about with the Children’s TrustHow can this be a driver of a health equity for children rather than a response to some sort of severe diagnosis?I think there is a lot to look at in terms of “What does this look like?” “How do we right-size it for every family?” “What are their needs and desires?”Not every family just needs access to cognitive behavioral therapyWe need to live in a more modular and family-responsive systemWe need to support the healing environments in communities that are relevant and connected to our own traditions and backgroundsSo the pediatric community has to be connected to the indigenous supports and services that are community built and community ledHow can that be paid for Medi-cal and led by the community, and how can families access those services.Laurie: What would a performance-based system look like--are there any models you think we should be aware of? Are you guys funding anything?Rajni: I think the work that Jeremy is doing will be relevant. How far along are we, what is the progress of the child and the family unit. How do we measure the extent to which a health system is trauma-informed. I think that is a good place to start. The other part of this, I think from a scientific perspective there is so much to learn about the translation of trauma and toxic stress, e.g.Is asthma and ADHD linked back to toxic stress?How do we even know if a kid is affected by toxic stress if their asymptomatic?Identifying biological and behavioral markers of toxic stressSometimes people say it's all about relationships, I don’t need a biomarker. But this can help us look at the physical health of the child, there is developing work on this. The next generation of science will probably lead us there. The Harvard center on the developing child, we have supported a lot of that, researching about how to talk to families about toxic stress, and what are the biological implementations. This would mean be collecting blood or hair samples, how do you even ask families to do that?Very sensitive issues, and looked at this as an addendum to the PEARLS study, something to look at through UCSF, the Bay Area Research Consortium.Mostly led by Neeta ThakurDon’t hear much talk about that in dialogs around screening.People get freaked out about biomarkers and otherwise.Speaks to where we are scientifically in terms of where we are with dealing with traumaAre we getting any better at identifying trauma, or healing families?Laurie: I’ve heard pushback in the past from law-enforcement about basing this in biology.Rajni: the patient and the family might also say, are you telling me that I’m brain-damaged, or I can’t get better. That’s a big part of the story that’s not getting talked about. Is the compassion for healing. Just from that experience, because I know how much push-back there was.Questions on financing:How can we take some of the ideas that have been integrated into the Resilience Collaborative to scale in California?What advice might you have on how to finance/support programs (clinical and non-clinical) to appropriately respond to the level of ACEs/Trauma in the Child Welfare population?Rajni: I think we need to blow it all up and start over. What’s really frustrating is that we can’t get the basics done in our system. Hard to get kids access to even CBT.We have to supplement so much of this with philanthropic dollarsHard to leverage those dollars beyond individualized services that can really be healing for families.The family unit versus the individual child. Supporting them through their experience of trauma while yielding to the best services for the kid. Need to help them as they manage their service(s).That requires a massive shift in our thinking about how our service was delivered.New and different ways for leveraging how EPSDT was servicing the support for how to build community for toxic stressNot a typical interventionWe don’t necessarily know what they are, how to build an evidence baseWe haven’t been good in understanding things like community prayer circlesThis is established in the youth development caseThat is where EPSDT needs to go, needs to be evidence based and respectful for how our tax dollars need to be used, but also needs to be connected to what our solutions will look like.Shawn Ginwright, Flourish AgendaNameShawn GinwrightOrg & TitleFounder and Chief Executive Officer of Flourish Agenda, Inc.Professor of Education in the Africana Studies Department and a Senior Research Associate at San Francisco State University.Current Chairman of the Board at the California EndowmentQuestions for All Interviewees:Laurie Kappe: Looking at children’s health as a whole, how does disproportionality play into the administration of children’s systems of care in California? Both from the behavioral health side and the physical health side.Shawn Ginwright:Young people of color in primarily urban areas have disproportionate exposure to trauma, disproportionate mental health need. The bandwidth, the availability of mental health provision is nowhere near enough to meet the demand and need for it. In many counties, much of the trauma and mental health needs go undiagnosed. The way that that manifests in mental health sometimes goes undiagnosed. What’s significantly important: we have to shift from only thinking about trauma and treatment for mental health from an individual perspective, we have to take a step back and take a much more robust and profound mental health view and look at the root causes of trauma in the first place. This means a paradigm shift for providers, medical schools, medical providers. Need to provide the therapeutic and medical workforce for a much more public health frame.Laurie: coming out of talking with Ken Hardy. In the new PEARLS screen, very much informed, but somewhat different than the original ACEs screen. Informed by her work and Dr. Burke Harris, they added questions about foster care, and have you experienced racism. So the conundrum there, is what’s the treatment modality for that? How do you inoculate against that?Shawn: so it’s not only how do we build and inoculated, and develop protective factors for young people who experience racism, that places the blame on the young person. You have to think about how to deal with the racism itself. So if you think of a person who’s laying on the ground and someone has a foot on that person’s neck. Resilience and protective factors say why don’t we make that person’s neck stronger? Vs. how do we take the foot of that persons’ neck.If we take a public health view, we have to take a look at the policies and conditions that lead to that trauma. How do we make investments in that process. How do we change that for treatment, structural treatment, but also collective treatment. For those that have been exposed to racism, how do we actually heal them from that exposure. It's about developing a sense of agency, goal orientation, concepts that are based in research, once you cultivate self-identity, culture, sense of agency, the ability to name what happened to you. To have a sense of future goal orientation, can lead to a sense of profound well-being. We need to shift from a frame, from how do we fix inequality, to a frame of how do we create structural wellbeing. To achieve structural wellbeing is another. That means, how do we create the systems the policies the practices the resources, putting them in place in ways that guarantee and saturate people with opportunity to be well. In New Zealand, the prime minister align the government budget around the idea of structural well-being. The criminal justice system, the education system was aligned about the idea of structural wellbeing.Laurie:As screening of youth and families in California is increasing, how can we as a state respond so that families are getting appropriate services? How do we assess?What programs and approaches do you see as promising (we are making an inventory).Shawn: so I think that there are a number of responses, but I make a distinction from treatment of trauma to healing from trauma. They are not the same: treatment means we are largely focused on symptomatology the abnormal behavior associated with trauma. If you conflate treatment with healing, then it's shortsighted. Healing means we are treating the symptoms but we are healing the young person and dealing with their symptoms and instilling a sense of wellnessWe focus on the ways identities have been harmed. Shame for the way they look, their name, their hair. Healing means we pay attention to that and we restore that. There are a number of efforts in California and around the country that are focused on healing. Doing more that just treatment.The National Compadres Network: they have an evidence based healing process where they use indigenous process to re-center the identities of former gang members, give them a voice to talk about what they’ve experienced.Restorative justice: not necessarily the complete answer.A lot of the work in Oakland we call “healing centered engagement”So our work here, assumes that many of the African American people who come to our programsWe don’t assume that some are acute and some are not acute, we assume that everyone has some exposure to traumaOur work is to focus on identifying to focus on transformative relationshipsFocus on voice, focus on identity how do you name what happened to you, having a sense of agency. Name what happened to you and name what you want.Future goal orientation, hope is a cure, and hope is can I see a possible future, can I imagine a possible futureTrauma limits what people imagine and think about Our work provides a process to find thatAll of these things get cut off with exposure to traumaI’ve heard this point from folks across the country: we also have to pay attention to the wellbeing of the therapeutic and social work workforce. Just because you have a good job it doesn’t mean that your wellbeing is all in place. Well Being and healing is a reciprocal process. In the medical model, its I give you medicine, you get betterIn the healing center way it's a reciprocal process my relationship with you, as an adult as a provider, gives me a sense of purpose, a sense of direction, a way to practice and have a sense of worth to help support their own wellbeing.A way to pursue their own wellbeing.Laurie: What would a performance-based system look like-- are there any models you think we should be aware of? How could we measure wellbeing, and show that we as a society are providing wellbeing and healing trauma?Shawn: I draw a lot of my thinking about what constitutes well being from Isaac Prellitensky’s research. I could send you some of his research. But to summarize: Prellitensky doesn’t see well being at the individual level, its an ecology of wellbeingIf you treat the symptoms the child then goes back to the school and they are exposed to trauma again.I borrow from James Gabarino, social toxicity, so Gabarino gives us a framework for understanding the conditions. Prelitensky gives us a framework on how to respond to itHe looks at dimensions of wellbeing at the individual level: self-identity, self value, sense of culture, self-worth.Looks at it from the family unit level: sense of connectedness, a sense of trust, sense of purpose.Looks at well being from the community level: closeness of relationships, amount of trust, some of the same relationshipsQuestions about performance measures, to understand whether or not wellbeing is being produced at the system can not be measured at the individual levelAssumes the individual can be well but his or her family or community may not beIf we situate wellbeing within a context if the community isn't well then neither can be that person be.Laurie: are you familiar with results-based accountability. Kind of starts from the same frame. Define what you mean by “we want to improve the wellbeing of our children” what would the indicators of wellbeing be? Once you have those indicators, what would the measures be? So it sounds like what New Zealand did, it sounds similar to what Vermont and other states did. What outcomes do we want? All kids ready for school, all kids thriving?Shawn: another organization I think about with this is the Ryse center. Laurie: in addition to RYSE are there other community based organizations or programs that you are familiar with that you think would be helpful for our inventory? We wanted to have examples of promising programs that work.Shawn: another organization here: Urban Peace Movement. Led by Nicole Lee, really doing some powerful work. Nicole and I wrote a paper a while ago about healing centered organizing. Did kind of a mapping about who’s doing healing centered youth work in California. You’ll see there’s kind of a mapping of healing centered work. My thinking about that has evolved somewhat but it gives me a sense of who’s doing that healing centered work in California.One other in Oakland: they work closely with Urban Peace Movement, they work with young men right off the street: Adimu Madyun facilitates Determination, its a program of urban peace movement.Laurie: A lot of great Oakland organizations I’m sure you’re familiar with:George Galvies, CURYJ, R JoyShawn: there’s another national organization: Forward Promise, it's actually a RWJF funded program, that started off at RWJF landed at UPenn, now it's run by Howard Stevens. Forward promise gave grants to a number of orgs. Across the country thinking about culturally grounding healing work.They have a cohort of 15-20 organizations, CURYJ, a couple of others you may already be familiar with. Howard Stevens and Rhonda Bryant head it up. They are trying to research and document some of the best practices. So how do you look at healing practices in cultures that may be really different. How do Native American communities look at what causes harm for young people of color vs. how is that looked at in the African American community.Laurie: It brings to mind, part of what we want to address in the paper, many of the programs your talking about, don’t have EPSDT contracts. It is an entitlement, really good work going on helping to heal children and families that doesn’t fit in with the modality of being a specialty mental health service, and could be underwritten by our tax dollars. People have different perspectives about this:Do you think programs you’re talking about would benefit from drawing down federal funding? Or is better if they’re not linked.Shawn: You’re familiar with Alex Briscoe, and Macheo is a colleague and friend of mind, so I think that what’s going on is. There are community driven wellness response that are off the radar of the science-based responses. The national academy of sciences, I am getting calls to go to grand rounds at medical schools, and going to the national conferences with physicians that there is a growing understanding about the myopic view of wellbeing and health. And there are ongoing practices and rituals to provide support for wellbeing that are completely off the radar map. And if there are easy ways for people to hook their hat on these responses, we would see and explosion of the radical responses in our communities to help people:Positive affirmation text messagesSweat-lodgesTraining barbers to have mental health conversations with young men that sit in their chairsBut they are likely not on the radar map of what’s considered “legitimate”Not so rigid ways of thinking about it, without those you could have Billing every 10 minutes etc.That mindset atomizes wellbeing, reduces it to billing and numbersWhen you talk to young men and women from CURYJ, it's not the amount of time you spend in it, is the quality of the time. I think that you and Alex and Macheo come together to figure this out.My brain is not around unlocked medical and state dollars around this.Laurie: what I hear from Kanwarpal we don’t want to pathologize young people to get to that point.Shawn: so you have to broaden that away from the current system where you have to diagnose something that’s pathologized. But if you live in a zip-code where there is profound mental health need then you don’t need to think about that.Laurie: we’ve heard that states and jurisdictions are hesitant because they worry about an audit down the road. So if we as a state where to indemnify the communities down the road, would they start support a wider array of programs than they are now.Shawn: these are our tax dollars going into this.Other questions:Anyone else you think we should include in the issue?Shawn: I think there is one additional thing you might want to think about AB 656, which is to establish healthy and safe communities. In that legislation there is intentional language focused on not pathologizing people, and it was starting off from the office of violence prevention. There is clear concise language in there about healing and well-being. I think it got extended into a two-year bill. Laurie:That’s not bad to have it as a two-year bill. Often that gives time for the legislature to appropriate the money and really consider it.Elizabeth Manley, University of Maryland School of Social WorkNameElizabeth ManleyOrg & TitleClinical Instructor for Health and Behavioral Health Policy at the Institute for Innovation and Implementation, University of Maryland School of Social Work(former Assistant Commissioner for NJ's Children's System of Care)Laurie Kappe: Can you talk about your experience integrating the physical health and behavioral health needs of children into one system of care?Elizabeth Manley: so I am familiar with model, not just from New Jersey but my work at the institute. When I was commissioner at New Jersey, we actually implemented the behavioral health home model. And use the system of care as the driver for that, integrate and connect physical and behavioral health in a single care plan, New Jersey has a unique challenge because it has a fully developed system of care. So other states that implemented the ACA they implemented new medical homes, had to shift their work into a particular placeWe used wraparound and a care management as a driver of care managementAnd brought medical professionals to the tablePut a nurse and a wellness coach around children that had a chronic medical condition including those who had developmental disabilitiesWe expanded the definition of chronic medical conditionsCould work with children w/.autism in a more broad wayWe used the state plan amendment mechanics to implement the behavioral home modelStarted in 5 counties“You have to move at the same time as the adult mental health system moves but you don't have to use the same model.”Laurie: California will be doing more screening, the pediatricians will be leading the charge. Question we have is once you do the screen, then need to put in place some assessment tools, and that supports/services, and perhaps a performance based system that would come up with the case plan:Elizabeth: A few things. So when the screen happens, sometimes the focus is what’s next? We jump ahead to an intervention. Sometimes we move too fast, what we know about children and families is that they heal within the context of the communityQuestion for us, how do we engage the community?So for us you try to reconnect a youth back into the communitySo you might have a pediatrician to sign a doctors note for a kid that might have a stomach ache, asthma, so the behavioral health system, they can do the thing where they hold your hand and help you walk back into the world. Help the kid move the direction towards their goals and dreams.In NJ when we attached mobile response stabilization for children going into foster care”They have a simple conversation with the family about what trauma isThey talk to the child about that and talk to the family about thatThey provide some tools for the child to useThey screen for the need for more services to go in initiallyThey look for a change in the child’s behaviorWe started to see the placement problems California is working hard to implement mobile response stabilizationLaurie: so in California after the Katie A. lawsuit, the accountability was a report with the penetration rates, did they get a service but not much about outcomes. If we are performance based, might include: Has anything changed for that child/family?What might we measure? For CW we measure reentries, reunification, outcome measures and we have clear physical health measures: asthma etc., but what would the behavioral health version of that look like?Elizabeth: when behavioral health is doing well you see the outcomes in different areas. You might be keeping a kid on track to graduate high school. They might be staying in residential care. So the behavioral health system outcomes shows up in other areas. NJ has a return on investment study coming out soon. I think one of the things you want to measure, does the child feel better?New Jersey uses the CANS, in the CANS you can see if there is some measure, doesFor other states they use different thingsOne thing: look at the community connections, are there more people sitting at the table, is a child back on the football team? New Jersey is trying to take that off the care plan and put it into the data dashboard.You can measure that within a care-plan:You can count how many people were there who weren’t getting paid.The rule in wraparound: if 70% of your team is informal support then the plan will work out even whenPart of New Jersey’s system of care expansion grant was to do a full ROI study on the implementation of the system of care it is due out in 2020.Tom Mackie: Rutgers university center for state health policyEvaluation of the grant itself and full ROI he has big datasets of medicaid and CANSWill be interesting to see how it turns out.Laurie: would be great to connect with him. We are hoping people in our state can get going with that.Questions About Screening/ProgramsLaurie: As screening of youth and families in California is increasing, how can we as a state respond so that families are getting appropriate services (e.g. substance-abuse treatment) while not rapidly increasing the number of families reported to CPS? What do we do with the dataset?Elizabeth: it's always complicated, I think the best model to do that is wraparound, it requires a peer-support partner that does the work with you, addresses the needs of the parent. The parent has been through it, they tease out the important challenges. Trying to get at the substance use issues is hard a thing to do. One of the best practice models for that. Because it's a foundational element. It tends to be the driver of systems of care change at the systems level, but also at other levels. Laurie: so with FFPSA wraparound wasn’t listed in the approved program.Elizabeth: States can put wraparound and mobile response in their plan. The Children’s Bureau is going to agree to that, it's not that you aren’t going to be able to use it. The evidence is pretty clear. The NJ study is also going to demonstrate why it's important.States can put wraparound in their plan, the Children’s Bureau has signaled that.In 2013, CMS and SAMHSA sent a letter to Childrens’ Behavioral Health depts. around the country and Wraparound and mobile response stabilization were included in this level.Children' bureau is really asking states, what do you want, we want to hear from you.The institute can help, we are doing a ton of work around Family First right now.Questions on financing:Laurie What is unique about financing a systems of care for children?For California, we have an opportunity medicare waivers coming up.Do you have examples of where EPSDT has been used in non-clinical interventions.What funding streams did New Jersey utilize?Elizabeth: it is one of the foundational elements in the system of care in New Jersey, its allowed us to do assessments to figure out where children are, connect them early for services and supportsNumber 1 we’ve been through audits, we were audited by New Jersey Medicaid first, then by the fedsThe oversight is what's really important There are a couple of adjustments, you can makePPL don’t call the public health system if they don’t need helpPeople won’t ask for service unless they need itCMS has some innovations that can mitigate the trauma, mobile response Number 2: You want to have a common screening tool, doesn't have to be CANS, need to be able to compare apples to applesYou have to be connecting youth to the right thing nextNot always outpatient,Knowing when and how to make those connections is importantExternal to the service providersThere is utilization management that reviews all plansFeedback to make the right intensity that the level of service is useI find that the states are spending a ton of money, they are just spending it in the wrong placesGetting upstream, interventions to children is a lot less expensiveResidential interventions, out-patient, they can be wastefulIf a child is not ready for it, if the family is not ready for it, it may not be workNeed to help people get the right service at the right time.Laurie: so with things like extracurriculars, non-clinicals, drumming circles, yoga, can you claim it under EPSDT, have states/jurisdictions come up with guidelines that are audit-proof.Elizabeth: so CMS does support the use of flexible spending. So flexible spending does support something like a drumming circle. So CMS pushed it and SAMHSA pushed it, there is a precedent in MediCaid. They will pay for kids to go to Yoga.The key to flexible spending, with the full-plan, whatever flexible spending is in the plan, need to identify that outcome in terms of flexible spending, they would see yoga in the plan, but also need to see how it would be sustained over time and what the goal would be right now.The devil is in the details.Can’t be something that Medicaid to pay for under a different mechanismIf it's something that you could pay for under outpatient, it would be covered.Other questions:Any research/studies we should know about?Elizabeth: have you seen the National association for state mental health program directors paper? [Making the Case for a Comprehensive Children’s Crisis Continuum of Care]Mobile response is one of the core-components that states consider for a crisis continuum for children. I will send it along.Frank Mecca, CWDANameFrank MeccaOrg & TitleExecutive Director, CWDAFrank Mecca: Note for framing, the trauma question can mix physical health and behavioral health. For Nadine Burke-Harris and Dayna Long, trauma discussion is more about the physical sideWhen we refer to performance based “systems of care” are really about behavioral healthQuestions for All Interviewees:Laurie Kappe: What would a performance-based system look like-- are there any models you think we should be aware of?Frank:I’m only going to talk about behavioral health. This is a child welfare lens, not a broader population lens. For the child welfare population, as a community of stakeholders we’ve identified and tracked, publicly made available, monitored, and improved to a set of outcomes. AB-636 (the California Child and Family Service Review System) there is a lot to learn in that model. What do we want out of a good system, what is it that we’re tracking: removals avoided, reduced family placement disruptions, etc. What are the indicators that we think would tell us that we’re doing OK in promoting children’s behavioral health. We measure a lot of things that I don’t think from a policy maker or high level management viewpoint, we’ve clarified a set of outcomes that we can monitor, report, and share with the public, and more importantly, set up a system of continuous quality improvement based on those outcomes. So on the state and local level would we have a continuous quality improvement measures that we want to make better?So lets say that a county has a really serious degradation in their timely adoption rates:So the county sets up a plan, the state monitorsIt doesn’t make the system perfect, but it can focus our efforts around what the public and leadership thinks is most importantIt would seem to me fantastic if we could distill the 10-15 things that matter the most that align with Child Welfare. We did that with CalWorks, we took the Child Welfare model and applied it in CalWorks.Its outcomes, measurement, transparencyCommunity-based, stakeholder-involved quality improvement planningNot gotcha, not a punitive systemAllows us to focus on improvement. Those are the good elements of any outcomes based system.Laurie: so the critique and narrative around behavioral health, post-Katie-A, we just have a measure of penetration rates, we don’t know how specialty mental health services are really utilized. I don’t know post-Katie-A, post-CCR, have there been any kind of steps taken, either at the county or state level to have a dashboard?Frank: there was a Jim Beall bill, not from this session but the year before, I don’t know where it landed. I would interview Jim Beall, his interest in behavioral health is beyond kids, may have a broader perspective, he’s the guy in the legislature that’s focused on it.Laurie: when Beall terms out, anyone you’re going to look to for leadership on this?Frank: not clear, maybe Joaquin Arambula.Laurie: so in the conversation with Dayna Long, she was sharing about next steps post AB-340, and said we should talk to you about it. Frank: DHCS by statue, has an obligation to have ongoing conversations about updating the screening tool, and an update on screening servicesRather than re-convene the AB-340 taskforce, in lieu of that, they are forming the BHSAC, Behavioral health stakeholder advisory committee.So some of the people from AB-340 are in the BHSAC, Kim Lewis, myself, so privately we are trying to figure out what are our next steps, wanting to figure out, what are the results of the screen, and what follow-up services, whether they are community services, or how to deal with physical health issues, what is the follow-up protocol so we can be more intentional about what we do.We need to think about the root cause of the physical phenomenon to try to deal with those external stressorsWhat navigational tools, external aids, can connect the primary caregiver to the community types of supports, food, domestic violence counseling, and the last of the three pieces; behavioral healthHow can we think through the behavioral and physical health, those who’ve experienced trauma/adverse experiences, how do we build out the early support so that those kids can thrive.I see it as kind of a three-pronged approach: screen results prompt a different way of thinking about physical health, behavioral health, and how primary care interacts with community-based support and services.BHSAC is an informal group.DHCS has embedded that ongoing work in the DHCS Behavioral Health Stakeholders Advisory Group.Laurie: is there transparency?Frank: there’s a list available: Laurie: Dr. Long said there are some issues this group would be resolving, on a macro level, for instance, what are we going to do with the data? Would it be anonymized and used in some way?Frank: I don’t know but I think you should try to interview someone at DHCS. Jennifer Kent’s behavioral health person is Brenda Grealish, ask her some questions about the scope of the behavioral health SAG? And its intersection with the behavioral health issues of AB-340.Laurie: so one of my fears that Dr. Long addressed was the potential CPS report increase due to screening. Had been a fear in their minds but the research didn’t support this.On a macro-level 5 Million kids on Medi-Cal if they’re all part of this screening, could potentially be a really-rich data set.Frank: the AB-340 task force, in its original work, the group was very insistent that the findings were coded in a way that you could identify the data you find and cross-compare the data you get from Medicaid and compare that research.Laurie: in terms of Dr. Long, they had a software program, it's called Qualify Connect, it's a case management program to connect a family with a caseworker, community health worker, is this something you are aware of?Frank: I suspect I am not familiar with it, but the issue of the day is OK we screen, now what? If anyone has a good idea of what to throw into the now what? They will get reviewed.Laurie: I asked Dr. Long, besides your program what else it out there? So with the Resiliency Beginning collaborative, its physical health based from what I can understand, 18 clinics from 9 different counties.Frank: my sense of the work that we’ve done so far with AB-340, the folks who come at trauma from a population standpoint, from Child Welfare or Juvenile Justice. We came at this because we had this imperative for kids that we need services, or we’re getting services way too lateThen there are people who were looking at kids who had physical health issues, and the research indicated it was from a history of trauma.They’re learning from us, we’re learning from them, we are born from the same imperative.I am conscious that I don’t want to leave behavioral health behind, this isn’t just about rates of heart disease and asthma, but also bringing down rates on the behavioral health side, JJ visits, interventions, substance use.Laurie: so the third objective on the PART 2 is how do we pay for all of this? You brought up that for behavioral health we have Prop 63 money, MHSA. So one of the issues that was raised in Pt. 1 what is the extent that EPSDT could and should be used, and used for clinical and non-clinical interventions. Including non-clinicals that may be more effective than clinical? Thoughts on that?Frank: so before we get to the people you should talk to. My observation is that the funding for behavioral health is complicated, there is a lot of funding in Prop 63 for early and interventional, EPSDT is early. One is billions of dollars, the other is a federal entitlement. The lines for what the funding can, may and shall be used for, the way one state uses EPSDT vs. the other. IS a very open conversation. Approaching it as a what did they do vs. what do we do. But more focused on how do we as a state administer the EPSDT program/ how do we leverage that but not take the place of Prop 63.For some counties they fund through Prop 63 stuff they could through Medicaid, and they give up a federal match. They do that because the audit process is so fraught.So to truly fund a trauma-informed system of care that goes from early to after-care, we haven’t looked at the whole system, we have to talk about that first.Laurie: who else should I talk to?Frank: have to give Michell Cabrera the first shot, then maybe the Steinberg institute, and I would be curious if DHCS has anything to say on the matter.Laurie: I was curious if the state were to give audit-insurance so to speak to protect the counties, would the counties take advantage of EPSDT?Frank: I’m not in charge, but the federal gov audits can seem arbitrary, they can be capricious, so let’s say we should decide as a state that we go for federal funding.The legislature would have to get behind thisOne of the big agendas for the behavioral health system is to simply claiming so you a behavioral health person doesn’t have to claim by the minute, and document everythingSo we need to train all the clinicians all the counties to deal with this appropriately, some counties have lost claims that others did not because one county might have filled the paperwork out alright.Simplifying, and training the workers, those are all part of putting forth a system of care that people should be provided, and those things should be reimbursed by the federal government, they are entitlements. If we think that these programs are essential, then we should be providing those services to those kids because they are essential for their wellbeing.Laurie: Richard Knecht wants to create a children's system of care institute.Frank: not surprised he’s doing that, he was part of the original system of care before the state decided they couldn’t afford it.Would be interested in seeing what Lishaun Francis from Children Now/AB-340 task group, she’s not necessarily child welfare.Sara Munson, Casey Family ProgramsNameSara MunsonOrg & TitleSenior Director of Knowledge ManagementSystems Improvement, Casey Family Programs,Questions for All Interviewees:As screening of youth and families in California is increasing, how can we as a state respond so that families are getting appropriate services? California is starting to use the screening tool PEARLS. Are there tools that you are recommending to do the assessment? E.g. CANS.Sara Munson: I can’t say what Casey is recommending. I haven’t done this work, but I have talked to folks who have. Laurie Kappe: If you could point to the right resources, then we could include them in our inventorySara: The NCTSN, they have the trauma symptoms checklistConnecticut has a similar kind of screeningIn most instances it's had to be connected to the capacity for a jurisdiction, make sure you have the trauma-focus, CBT, Parent-Child interaction therapy, some of the evidence-informed interventions.Connecticut has done the most work to modify their policies and practices to make those things available for all agencies, not just through hotline calls.Laurie: What programs and approaches do you see as promising (we are making an inventory).There will be 6 Million kids screened for ACES in CA.We want to give sort of an inventory of folks. For the pediatricians and CW advocates. So they can see if what they see in the PEARLS screen is having an impact on physical and behavioral health. Second question:--once we screen, what are the promising or well-supported programs that we can list. Has Casey done an inventory of interventions that you are sharing?Sara: One brief is something called “what steps can our agency take to become more trauma informed?”Look at the list, it covers things that are specific to child protectionCovers evidence-informed modalitiesI think there are five.Laurie: What would a performance-based system look like to prevent or intervene with the effects of trauma-- are there any models you think we should be aware of?The way we measure post Katie-A is centered on penetration rates, but the way we show access to EPSDT, is if there’s been a claim for specialty mental health.Are there state/county administered behavioral-health departments or practitioners you think are on the right track in doing this workSara: in this case, in Connecticut, you would take the screen that would be delivered, and see what services had been delivered at some point in a given time in the future. So these screens aren’t necessarily designed be done only by CPS or only by clinicians.You would look at the reduction in trauma-symptoms specificallyThere are other orgs. That have looked at those proximal outcomes.So those are some of those performance based outcomes or benchmarksReductions in placements, elimination of residential care.Placement movesThe child-welfare interventions that are hurting the kids they are designed to help.What we call child-welfare CFSR outcomes.And now we know a lot more about secondary trauma. A traumatized workforce struggles with engaging families in a thoughtful and healing intervention. Trying to prevent high-turnover and workforce development. Those things can have an impact on families’ experience with the system and not have an impact on them. Compassion fatigue, or compassion/satisfaction. A proxy for how the family feels.Laurie: regarding the PEARLS screen, thinking what is next is the assessment, if anything shows up on the screen should they have a physical or behavioral assessment, and based on the assessment would we link them to some kind of service.Sara: usually it's a 10-point trauma screening, and then there would be an actual mental health assessment.Laurie: so you’re saying when you did a pre and post assessment, if a child is showing different symptoms, physical or behavioral, you would then look at the difference a few months later.Sara: I don’t know what the capacity is across California.They identify for example, are you reacting to certain events.Do you have mental health needs, etc.Laurie: you wouldn’t re-administer the PEARLS at that point.Sara: you are casting a wide net, trying to identify potential points of intersection. Have you looked at the NCTSN website, I know they have one on what's screening vs. assessment? They just redid the tool-kit too.Laurie: With the newfound recognition of ACES/trauma no longer have to convince people that it matters. Next question is how do we finance this? In California it would be a lot of interest in how do we us EPSDT, Title IV-E, Medicaid, FFPSA, wondering whether or not you from Casey have good examples for us on where we could mind for financing.Sara: I’m not the financing person, Joan Smith, John Winstead consults with us, does some of financial technical assistance. We’ve captured some of it, we have some webinars. I can’t remember specifics right now. Especially if it's in the context of a school setting vs. a social service setting.Laurie: we have a lot of orgs. Doing non-clinical, culturally based modalities. It's our tax-dollars, if these modalities work, why should they not be claimed and used. There is a growing movement who either object them or embrace certain funding sources. So some places don’t want to subject children to a trauma-screen to try to draw down federal money using a diagnostic model. Sara: are you familiar with the Futures Without Violence, they did a piece on this? Also my unit has a contract with the Center for Health Care Strategies.Laurie: I want to give the community orgs that are doing all this work, that are primarily funded by foundations. But they can’t go to scale with foundation dollars.Sara: maybe SAMHSA. The DAO from this year.Laurie: we can point to some examples. Even though states can be individualistic, especially California. A certain subset of policy-makers do pay attention to that.Sara: that might be California specific. We get questions from not just Child Welfare directors, legislatures and judges too can send in lots of requests too.You can do all the work around the screening and assessment and intervention and not do the other work for the families about how complex these systems can be, how to help them navigate. So if the system itself is traumatic and we need to attend to it, when I need to interact with our healthcare entity it is challenging. How do families get to services that aren’t accessible, every family needs a navigator or a case manager, even if a bunch of clinicians could have the bandwidth to do the right kind of evidence-based practices. Do it as a one-stop shop, including the non-traditional services you’re talking about. But also other pieces that impact the families ability to do well. Not having a house, a good school-system, all the things that are trauma inducing outside of a clinical level. Stuff outside of trauma. There are other services wrapped around that. Do I have to go to different places for different therapies?Peter Pecora, Casey Family Programs/University of Washington School of Social WorkNamePeter PecoraOrg & TitleManaging Director of research services for Casey Family Programs and professor for the University of Washington School of Social WorkQuestions for All Interviewees:Laurie: looking at all of the systems, in addition to child welfare, which include behavioral health, education, health care, --what would a really performance-based system look like if we tried to measure the impact of the interventions to mitigate and heal from trauma?Peter: It starts with what CA is doing--are you using a standard set of assessment tools? , so if a physician is Stockton is using a basic set of assessment tools, such as behavioral assessment tools different than someone in Sacramento, then you’re starting from a different place. If you have a standardized set of assessment tools, can you are more able to measure progress.You can see if you’re wasting time and money on something that’s not showing improvement.So regular performance monitoring using a standardized set of behavioral health assessment tools is another key to having a performance-based system.Laurie: Are there other places in the country you think are doing this well?Peter: Nadia Sexton (Nadezhda Sexton), understands child welfare and behavioral health very well, she has a ton of experience and a lot of that experience is from NJ. But she also used to work for Casey.SAMHSA has invested a ton of money into systems of care and some of those projects went really well.Laurie:If we were to create a dashboard that could show what a performance-based system of care is doing to prevent and intervene with the effects of trauma, what should we be measuring for that, what should we look for in terms of data? E.g., mental and physical health indicators, educational outcomes, others?Peter: Given that the staff turnover rate in behavioral health is too high, having a standardized assessment package that the state and the state behavioral health association, endorses would be wise. With that collaboration, every new staff person can be brought up to speed about the assessment tools that California thinks are important for their families. Setting a foundation across the state via videos and other strategies from the regional CW training academies should help be a more efficient way to get staff on-boarded.Christine Beyers, the new leader of NJ, is not focusing on the state’s class action lawsuit; instead she wants to see where their system needs to be overall. By not focusing on the narrow scope of the lawsuit, one can focus on the whole system.Laurie: that’s where we’ve been at with Katie A.Peter: I think San Diego pilot-tested MATCH–it’s a very efficient way to train people in four different evidence-based approaches. It calls out the core elements of all four mental health conditions:AnxietyDepressionDisruptive behaviorMild to moderate traumaCheck out the websites for match via the co-founders Bruce Chorpita (UCLA) and John Weiss (Harvard).It gets behavioral health staff up to speed quicker, and the Maine behavioral health managers felt like it helped their retention level. University of Maryland has developed a similar kind of approach for a parenting intervention. So you may want to research both of those. These constitute more efficient ways to get behavioral health professionals up to speed on a treatment approach.Peter: There are measures to use. Most states are using the CANS, so California will have some comparison data. Hopefully the CANS version you have will have the protective factors scale built into it. Beyond that you’ll want a trauma-screener, depending on how satisfied you are with how well the CANS assesses that area. It depends on what the particular areas of difficulties are with the child.For example, if the child is showing autism-style disorders, you need a specialty assessment. With complex trauma, CANS will only get you so far, so you may need an additional screening measure, something that is supplementary-- a more advanced screening tool. There are substance abuse screeners and assessors, there is anxiety, depression, the Beck [Depressive Inventory], the Baby Beck are supplementary.CANS can get you pretty far, so it's a matter of whether you want those assessment tools in the Behavioral health toolbox.I have a diagram that shows what trauma informed assessment looks like, so if you’re talking about case-planning for a youth, what are the strengths and case-factors operating for the youth across multiple dimensions.What role does that play?I use this diagram in presentations to emphasize that we really need a multidimensional assessment of children when they come into contact with the child welfare or behavioral health systems. If you have case management and resources you have to think more broadly. It's not enough to just look at behavioral health need to look a physical health, as well as aspects of sexuality and spirituality.If you want a trauma-informed system of care, I have a diagram I’m including from the SAMHA and NCTSN websites. It’s online, and in what I’m sending to you.Laurie: we had a long debate in California over CANS.Peter: People complain about CANS, but it's good to remind people that Casey and the Sierra Health foundation teamed up with CDSS, some counties and group care providers to evaluate the RBS group care reform, and we used the CANS scores to help document the kind of progress that youth need to make.It has clinical sensitivity, it shows change over time.It can inform case-planning, accountability and measurement.Laurie: we are going to interview some people who are interested in creating a dashboard around it.So presumably now that we have all this screening pediatricians sending people to resources, including potentially CPS. Do you have a grid that can show us assessments for age groups.Peter: we have a table we’re creating with a table of toolsWe also have a brief from Casey knowledge management. Laurie: we are also looking at what are the clinical and non-clinical interventions, so are there programs that are evidence-based, well supported or promising, that will be eligible for IV-E funding under FFPSA? We want to give direction on how potentially EPSDT can be used to reimburse some of these interventions if the child’s diagnosis and care plan is more coordinated and integrated. Pediatricians, Child Welfare leaders, and others in the field are more aware of trauma exposure for other children.Peter: EBPs can be a great resource to agencies on so many levels.We have an interventions catalog where we’ve reviewed with their evidence levels. This catalogue is intended to show all levels of government that there are a fair number of interventions that have some evidence behind them.Questions on financing:Laurie:What advice might you have on how to finance/support programs (clinical and non-clinical) to appropriately respond to the level of ACEs/Trauma in the Child Welfare population?Are there systems in other states you think we should examine?Do you have insight on how EPSDT can be used on assessment and interventionPeter: this is where Nadia could be used to point you towards some innovative ideas.There is this concept of fund mapping where you look at all of your strategies to help think through what is the best approach for those?Then you can braid and link those funding structures in hopefully more cost-effective ways.And then you can pursue more Medicaid billing codesCould CA be able to draw down more money under those building codes?Laurie: if CA at the state level gave direction on what they would endorse or reimburse the countries for certain services, and indemnify them from an audit.So most counties have preferred providers, some have been more innovative and adventurous.So some tribal nations are pursuing, for example, having drumming circles and other native healing strategies or Native American children approved for FFPSA funding.Some of these may have more of an impact than other interventions.Peter: In my list we include many examples, such as these: Drumming, sweat lodges, yoga, equine therapy,To what extent can a state help endorse these? Evaluate these? Some children don’t respond well to verbal therapy/talk therapy. So the agencies, they have to work very hard to help that child get re-regulated. This is where equine therapy, yoga, drumming, and physical-based therapies are being talked about as part of a cutting edge approach to mental health services.Laurie: so the point is can we get it paid for?Peter: Right, there may need to be a Medicaid waiver, or there may be multiple funding strategies you can try and evaluate at the same time.That’s where everyone in the field seems to be going right now.Laurie:We also have the advantage of the mental health services act.Can we use MHSA more creatively to draw down for these therapies?Peter: That would be excellent.Laurie: so my last question, now that you’ve looked through the issue, and you know who our audience is, any other comments or recommendations that you might have?Peter: Before anyone rushes to align or realign the California array of treatments or other interventions, it is essential to look at the data about what the children and families really need, including having families help you look at that data.We looked at different states and found so many of those children were being sent to group care, but really they could have been treated closer to home, or not removedSo look at the buckets of youth, what are the services they need, how do you target those servicesEspecially with California: pay attention to service dynamics, systems have perverse motivations sometimes. We’ve heard in the past that adoption and child welfare weren’t even communicating, couldn’t plan for permanency.Talk with Bryan Samuels, he led the Children’s Bureau. He told us that for one reform, the team didn’t think through the system dynamics in parts of Illinois and the initiative was badly hampered. They were at a strategic point in the reform process, and we had not thought that through.Laurie: would you think he might be a good interview for this topic?Peter: Bryan Samuels has great ideas about considering system dynamics and system barriers.In terms of addressing system dynamics well, in California the partners thought through many of the system dynamics with the RBS reforms. They worked really hard at getting the group care providers, county and state government leaders to come together and plan collaboratively. And this occurred even in the middle of a lawsuit to raise the group care agency rates!It was impressive to see how different people came together and thought about how they could make that system work better for children and families. ................
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