Transforming Residential Interventions

Practical Strategies and Future Directions

Beth Caldwell, Robert Lieberman, Janice LeBel, Gary M. Blau, Beth Caldwell, Robert Lieberman, Janice LeBel, Gary M. Blau

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781351187459
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Transforming Residential Interventions: Practical Strategies and Future Directions captures the emerging changes, exciting innovations, and creative policies and practices informing ground-breaking residential programs. Building on the successful 2014 publication Residential Interventions for Children, Adolescents, and Families, this follow-up volume provides a contemporary framework to address the needs of young people and their families, alongside practical strategies that can be implemented at the program, community, system, and policy levels.

Using the Building Bridges Initiative as a foundation, the book serves as a "how-to manual" for making bold changes to residential interventions. The reader will learn from a range of inspired leaders who, rather than riding the wave of change, jumped in and created the wave by truly listening to and partnering with their youth, families, advocates, and staff. Chapters provide real-time practice examples and specific strategies that are transformational and consider critical areas, such as family and youth voice, choice and roles, partnerships, permanency and equity, diversity, and inclusion. These methods benefit youth with behavioral and/or emotional challenges and their families and will improve an organization's long-term outcomes and fiscal bottom line.

This book is for oversight agencies, managed care companies, providers of service, advocates, and youth/family leaders looking for an exemplar guide to the new frontier of residential intervention. In this era of accountability and measurement, it will become a trusted companion in leading residential interventions to improved practices and outcomes.

1
Transforming Residential Interventions

A Practice Framework

Robert E. Lieberman, Janice LeBel, Beth Caldwell, Joe Anne Hust, Julie Collins, and Gary M. Blau

A Parent’s Reflection

“P roviders were lined up on either side of the foyer. I was standing alone, off to the side of the room, feeling extremely uncomfortable. It was June 2006, and I was in Omaha, Nebraska for a summit. I had been cautioned about the long-standing disagreements between residential and community-based providers and as I eyed the crowd, it seemed apparent to me that the lines had been drawn. It was reminiscent of an eighth-grade dance with boys and girls lined up on side walls so they could size up the other side. I wondered who would succeed as champion. I also questioned why I was there, as a parent. Fast forward to 2019, and I asked a colleague the other day if he remembered how he and another residential provider pulled me aside at the summit and asked me if I could talk to the other parents to ‘calm them down’ so the providers could get on with the agenda and business of the summit. He replied, ‘You mean the day the parents took over and the next day when the youth did the same?’ It wasn’t exactly the response I was looking for, but it was accurate. The tensions were definitely palpable. If that parent and youth ‘takeover’ had not taken place, I sincerely doubt we would have the Building Bridges Initiative today. It was a day of reckoning for both residential and community-based providers. Services and interventions cannot be designed successfully without a genuine partnership with youth and families. Partnership is the foundation for the Building Bridges core principles.

Today, I am no longer that uncomfortable parent. I am still involved with Building Bridges and leading three states in BBI Quality Improvement Collaboratives. As you read through this second book and wonder how you might integrate BBI practices, I urge you to embrace partnerships with families and youth, and you will be halfway to home.”

—(J. Hust, personal communication, July 25, 2019)

The practice of what has historically been called “residential treatment” has evolved and improved significantly over the past decade. This has been in response to a number of practice, policy, and financing factors; emerging research; and, perhaps most importantly, because of the engagement and empowerment of families and youth who have experienced this level of intervention. Collectively, these factors, experiences, and lessons learned have been the impetus to improve long-term outcomes post residential discharge for youth and families. Progress has also been made by re-conceptualizing how services are delivered, a greater emphasis on data collection and outcomes measurement (particularly post-discharge outcomes), and transformational changes at the provider, managed care, and oversight agency levels.

Five years ago, the book Residential Interventions for Children, Adolescents, and Families: A Best Practice Guide highlighted the emerging knowledge about the core components of successful residential programs and a redefined role for residential interventions in communities. The volume asserted the importance for residential providers to be part of community systems of care and addressed the tensions between residential and community providers, payers, and families and youth. As demonstrated in the title and opening paragraphs, the book offered the new term—residential interventions—encompassing all different types of residential programs. This intentional shift in language was a way to move the residential field away from the mindset of placement/a place for youth to live and receive treatment within the program to that of a short-term intervention, with a primary focus on engaging and supporting youth and families in their homes and communities, using a range of culturally and linguistically competent, family-driven and youth-guided, trauma-informed, best, evidence-based, and evidence-informed practices to address their needs and strengths. The new term has broad implications, as reflected in the compendium of strategies identified in the 2014 book and the changes in the field since. “Treatment” becomes something that happens through the practices and strategies available for both youth and their families—in the program and in their homes and communities—through strong partnerships with community services and supports. “Care” is available to the youth from their family, extended family, advocates, and residential and community staff. And honoring all cultures and diverse backgrounds equally—with equity, diversity, and inclusion—becomes more the norm than the exception.

The 2014 volume identified key themes: Using and disseminating the new terminology and mindset; creating and sustaining partnerships between all involved in the life of a youth and family; ensuring the essential role of family members and youth as drivers, through voice and choice in individual and organizational planning; understanding and implementing the vital significance of trauma-sensitive practices; embedding the importance of cultural and linguistic competency; and defining and measuring outcomes, especially post-discharge, long-term. The book provided a foundation from which to develop and implement best practices and offered multiple starting points for those who may feel overwhelmed at the task of change and transformation, invoking Lao-Tsu: “A journey of a thousand miles begins with one step”(Blau, Caldwell, & Lieberman, 2014, p. 226).

The Current Terrain

The 2014 book was an important factor in galvanizing the support needed and training required to implement transformational changes in delivery of residential interventions, and the past five years have been witness to several significant shifts in the expectations, policies, and vision that govern residential programs. Examples include:

• Residential providers are beginning to: Understand the necessity of shorter lengths of stay, recognize the importance of preventing and striving to eliminate restraint and seclusion, value and pursue partnerships, realize and respond to the impact of overwhelming stress and trauma, and believe in the importance of measuring post-discharge outcomes and impact;
• national associations are adopting the term “residential interventions”;
• state and county oversight agencies (17 thus far) are adopting the national Building Bridges Initiative (BBI), a framework for implementation of the strategies and practices identified in the book, to support alignment of residential practices with research on improving long-term outcomes post-residential discharge. These agencies have implemented formal and comprehensive residential transformation initiatives via policy, regulatory, and/or fiscal mechanisms, incorporating BBI principles and practices and/or research into their work. A number of other states have adopted BBI principles and materials to improve residential practices and/or oversight agency mechanisms to support improved youth and family outcomes post-residential;
• new federal law (2018), the Families First Prevention Services Act (FFPSA)¹ is establishing expectations and requirements for “Qualified Residential Treatment Providers (QRTP),” consonant with the spirit—and in some cases, the specifics—of the themes described previously. The FFPSA marks a turning point in the evolution of the residential field, as for the first time stringent residential requirements are explicitly detailed in national law. While it technically applies to a subset of residential programs—those that receive Title IV-E dollars through the state or tribal Title IV-E agency—the new law sets a bar that, by proxy, extends to all residential interventions. A bi-partisan product of extensive stakeholder negotiation and collaborative compromise, FFPSA builds on established mechanisms that assure a baseline of quality (accreditation that includes a focus on quality improvement, presence of medical personnel, and initial and ongoing assessment with a utilization review process) while also specifying practices that reflect the latest knowledge and evidence regarding what produces sustained positive outcomes (family-driven and trauma-informed care, provision of appropriate clinical services, shorter lengths of stay, focus on permanency, post-discharge support and services/family based aftercare, and outcomes/impact measurement).

The FFPSA thus brings together infrastructural elements that were historically available to the field of child welfare with newer transformative practices and shifts the historic tensions noted earlier to more nuanced and potentially productive challenges, e.g., embracing a transformational mindset, redefining the goals of a residential intervention, engaging family members whenever possible—even when there have been significant challenges in the household, involving youth in their family and permanency team to inform decisions about their own lives, designing efficient measurement systems to know when youth and families have the supports and skills to live together safely and successfully at home, and impact measurement to prevent cost shifting to the juvenile justice system.

Building Bridges Initiative

BBI was identified in the previous book as a “key driver,” providing the guiding principles and framework for operationalizing new practices and strategies. The principles and framework have driven policy change in dozens of states and practice changes in hundreds of provider organizations, impacting thousands of individuals. BBI is not a model or a prescription; rather, it provides a framework and a foundation for residential transformation and articulates the values, principles, strategies, and practices that are consistent with research on improving long-term outcomes for youth and families post-residential discharge.

The BBI principles, as identified in its formative document, the Joint Resolution, bear repeating.

Table 1.1 Building Bridge Initiative Joint Resolution Principles

• Youth-guided;
• Family-driven;
• Culturally and Linguistically Competent;
• Comprehensive, Integrated, and Flexible;
• Individualized and Strength-Based;
• Collaborative and Coordinated;
• Research-Based;
• Evidence- and Practice-Informed;
• Sustained Positive Outcomes

For each of these there is a growing set of resources available on the BBI website (www.buildingbridges4youth.org) that help guide dialogue and decision making for youth, family members, residential and community providers, advocates, oversight agencies, and payers. When these resources and guides are used and incorporated into daily practice, the successes and lessons learned advance the body of knowledge and pragmatic experience in ways that compel transformation of residential and community interventions in an integrated fashion that leads to improved lives.

Purpose

This second volume is intended to capture the emerging changes, exciting innovations, creative policies and practices, and latest advances in the science, research, and evidence informing the work. This book aims to build on the previous text, serving as an extension of that work, and an update on lessons learned. The specific purpose is to address the key themes from the first book noted previously and highlight transformational approaches at the individual level (youth, family, staff, and advocates), the program level (residential and community providers, family and youth-run support organizations), and the system level (government oversight and financing, including managed care companies). It goes beyond the first by focusing on broader policy, financing, and system change factors to improve residential interventions; examining strategies to incorporate meaningful evidence and outcomes measurement; exploring brain science and its connection to the BBI framework; and taking a closer look at the critical importance of permanency and equity, diversity and inclusion.

In seeking to foster the wider and deeper changes needed at all levels of the system, the book is organized into chapters that examine and provide essential elements for residential and system transformation. Each chapter provides a discussion of the pertinent issues and offers guidance, tips, strategies, and resources, along with references to the science, research, and evidence and, for many chapters, contact information that may be useful on a transformational journey. Of course there remains much more to explore than this volume can cover in the effort to continually identify and refine best practice strategies, in areas such as: Workforce retention, transformation for oversight agencies, social justice, services for rural youth and families, education, sibling supports, families formed by adoption, addressing the different types of individual challenges parents and families face, and specialty services, including for youth who are LGBTQ, sexually trafficked, hearing and visually impaired, substance using, intellectually disabled and/or on the autism spectrum, and their families. With more progress to come, perhaps a third volume will follow!

Each chapter has one or more youth or family members as co-authors or contributors, in keeping with the BBI value of ensuring family and youth are at the table, their presence respected, their voices heard, and their recommendations given primary attention. In working toward diverse representation, the editors have also striven to ensure that the chapters have lead or co-authors and contributors representing a marginalized community and/or that experts in equity, diversion, and inclusion and cultural and linguistic competence have provided input.

Terminology

Once again it is important to make mention of the terminology used in the book. The term “youth” essentially is meant to include children, adolescents, and young adults, unless the context indicates a more specific age referent, or the more generic “young people.” The term “residential interventions” remains as defined in the first book. This continues to be a more appropriate term that reflects many different types of treatment and support approaches. The term residential treatment, for example, can be misinterpreted as something that happens only in a residential setting, when in fact, best residential practices occur in the home and community as well as in the program. When referring to something that occurs within a residential sett...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• About the Editors
• About the Contributors
• Acknowledgments
• Preface
• 1 Transforming Residential Interventions: A Practice Framework
• 2 Putting Families First: Strategies to Transform and Advance Family Engagement and Partnership
• 3 Youth Engagement and Empowerment Strategies
• 4 Advancing Equity, Diversity, and Inclusion in Residential Interventions
• 5 Residential Transformation: Successful Strategies and Examples
• 6 Residential Intervention Strategies to Accelerate Permanency
• 7 Residential Oversight Agencies: Successful Strategies and Examples for Residential Transformation
• 8 Establishing Partnerships to Improve Aftercare and Long-Term Outcomes for Youth and Families Served Through Residential Interventions
• 9 Evidence-Informed Residential Programs and Practices for Youth and Families
• 10 Understanding and Applying a Neurodevelopmental Approach in Residential Interventions
• 11 Measuring the Impact of Residential Interventions: A New Frontier
• 12 Developing Fiscal and Financing Strategies for Residential Interventions
• 13 Residential Transformation: Taking Change to the Next Level
• Index