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Improving Outcomes in Residential
Kaitlyn Harrington, Kristin Williams-Washington, Beth Caldwell, Robert E. Lieberman, and Gary M. Blau
Introduction
Now more than ever there is a need to ensure that best practices are being used in residential programs. As the focus on costs and outcomes increases, residential programs must demonstrate that the interventions provided are efficient and effective. The good news is that we now know more than ever before about the core components of successful residential interventions and what works. There is research, practice-based evidence, and compelling testimony from children, adolescents and families about what works. For example, we have learned how to:
- create strength-based, empowering, and healing environments;
- better engage and partner with children and adolescents (hereafter referred to as āyouthā) and families in a meaningful way;
- support those who have experienced trauma and/or loss, and prevent and strive to eliminate restraint, seclusion, and all coercive interventions;
- respect and include cultural indices in practices;
- train, mentor, supervise, support, and empower staff to deliver promising, best practice and evidence-informed, and evidence-based interventions; and
- track long-term outcomes and utilize different funding strategies to better support sustained positive outcomes.
Simply put, we know how to improve residential interventions, and this book was developed to push the field towards implementation of the practices that can achieve the best possible outcomes. Moreover, to assist you, the readers, in implementing best practices, this book contains information, tips, and resources to guide you and inform your work.
Purpose
The purpose of this book is to help organizations, communities, and systems improve the services and the integration of care that both families and youth experience as they navigate residential programs from intake to the transition to community programs and supports. Each chapter is intended to provide practical, specific strategies and promising and best practices that can be used to improve services and outcomes for youth who receive residential interventions due to emotional, behavioral, and/or other life challenges, and their families. The aim is for the readers to gain how-to ideas that will enable them to make a difference in the services and supports provided for youth and families receiving residential interventions. Specifically, the goals of this book are to:
- articulate the values necessary to successfully incorporate residential interventions in the array of services for youth and families;
- identify and describe effective, promising, best and evidence-informed and evidence-based practices that residential leaders can use in partnership with community providers, advocates, families and youth, and funders to improve services and long-term outcomes;
- provide references, resources, and documents that create a blueprint for residential providers to improve practice and long-term outcomes (this how-to approach will include techniques for self-assessment and planning, culture change strategies, benchmark and outcomes management, strategies to incorporate youth and families in services and organizational decision-making, and a framework for policy, financing, and system development); and
- identify the steps and content needed to create action plans to develop and implement principles and practices that will lead to sustained, positive outcomes for youth and families who are touched by residential interventions and systems.
Audience
Generally, this handbook should prove useful to individuals with the desire to learn the fundamental principles of best and evolving residential practices and apply them to their existing knowledge of services and supports in residential settings. The audience for this handbook includes:
- residential and community staff across all disciplines and all levels;
- medical and clinical staff at all levels of an organization;
- residential and community provider executive leadership, including members of boards of directors;
- policy makers at the city, county, state, and federal levels, and within tribes and territories;
- advocates;
- individual families and youth; and
- anyone who is interested in improving residential service delivery and outcomes at the federal, state, local, and provider levels.
The truth is, from our perspective, this book can be used by a whole host of people who are interested in improving residential services. The key is whether and how you, the reader, will use the information to effect real change.
Are Residential Services Even Necessary?
Our belief is that residential is an important component of a comprehensive system of care. Thus, the simple answer is yes, although not in the way residential services have historically been delivered. The first chapter of this book delves into the history of residential programs in order to better understand what has worked and what has not. It is important to focus on what does not work to develop alternatives that do and that become best practices. There is also a need to understand the tension and friction that has existed between residential providers and community-based providers. This tension arose due to philosophical differences in approaches, roles, and responsibilities. For example, community-based providers have often believed that residential interventions lack a solid evidence base to validate their effectiveness, and that they keep youth too long. On the other hand, residential providers have believed they are often unsupported by their community-based colleagues, particularly when they are needed to assist with appropriate discharge planning. To address these tensions, and to support the need to include both community and residential programs as part of the service array, the Building Bridges Initiative (BBI) was developed.
Building Bridges Initiative
The Building Bridges Initiative has been a key driver in the development, implementation, and measurement of the practices and strategies contained in this volume. BBI is a national effort to promote a dialogue and provide a framework to address the identified issues through advancing consistent principles and coordinated practices across the full array of residential and community-based services (see www.buildingbridges4youth.org). The initiative emphasizes closely coordinated partnerships and collaborations between residential and community-based service providers, families, youth, advocates, and policy makers to successfully introduce and implement change in both policies and practices in communities across the nation. This framework has resonated throughout the field as states, counties, national associations, residential and community program practitioners, families, and youth have formally or informally used BBI products and principles to improve practices.
The BBI core principles were developed after a summit meeting that occurred in June 2006. As a result of this meeting, which was attended by residential and community leaders, government officials and policy makers, advocates, and families and youth, a joint resolution (JR) was created, reflecting consensus about service delivery values and principles (see www.buildingbridges4youth.org/products/joint-resolution). The JR includes a list of specific values and principles that, if shared and implemented, would result in positive improvements for agencies, communities, and systems, and improved long-term positive outcomes for youth and families served. These core values and principles are shown in Table 1.1. The BBI framework is designed to implement these principles and to strengthen partnerships between community based and residentially based treatment and service providers, policy makers, advocates, families, and youth and to generate an effective approach for all service providers. It has been used as a platform for practice innovation that has led to transformation of residential services in locations across the country and that has galvanized significant work towards long-term positive outcomes.
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
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Terminology
It is important to understand some of the terminology that will be presented in this book. The term youth essentially means children and/or adolescents. Furthermore, when the context indicates only children or adolescents or young adults, these terms will be used. Sometimes, for example, in order to mix it up, someone might use young people or may want to specify a particular age group. In addition, this book will primarily use the term residential intervention, as this book will be applicable to many different types of residential programs (e.g., residential treatment programs, group homes, residential centers). We believe that intervention is a term that more accurately reflects the current research regarding residential best practices and moves the use of residential away from being a placement, or a place to live. The focus is not primarily about what happens inside a residential program but rather on using the residential resource as a short-term intervention to identify a range of practices that can occur in the homes of families and in their communities.
Chapter Organization and Topics
The following topics will be covered in subsequent chapters within this book. Each section will provide information, guidance, tips, and other resources useful to those providing, funding, licensing, advocating for, or receiving residential interventions:
- Family-Driven CareāFamily driven means families have a primary decision-making role in the care of their own children as well as the policies and procedures governing care for all youth in their community. Chapter 3 will explore, through tangible and practical examples, the importance and benefits of incorporating family-driven care as well as some of the challenges providers can face and how to overcome them.
- Clinical Strategies for Engaging FamiliesāThe goal of Chapter 4 is to describe, define, and identify evidence-informed and evidence-based clinical strategies that can be used successfully to engage and motivate youth and families in the entire treatment and support process.
- Youth-Guided CareāYouth guided means that youth are engaged as equal partners in creating systems change in policies and procedures at the individual, program, and community levels. Chapter 5 will help readers understand the principles, strategies, and challenges in developing and maintaining a youth-guided program.
- Cultural and Linguistic CompetenceāCultural competence is the integration and transformation of knowledge, behaviors, attitudes, and policies that enable policy makers, professionals, caregivers, communities, youth, and families to work effectively in cross-cultural situations. Chapter 6 provides a framework for residential programs to address cultural diversity through the effective infusion of cultural and linguistic competence in all program interactions and engagements.
- Trauma-Informed CareāTrauma-informed care (TIC) is an evolving organizational approach to recognizing and responding to the impact of trauma. Chapter 7 reviews definitional challenges related to TIC; examines the facets of creating interpersonal and physical environments, services, and supports that are sensitive to the issue of trauma; and provides pragmatic recommendations to successfully implement TIC.
- Linking Residential With CommunityāResidential and community services have historically operated as discrete and separate entities. This separation creates unnecessary fragmentation in treatment, family participation, discharge, and continuity of care. Chapter 8 will discuss the benefits of linking residential and community efforts and provides examples and strategies for doing so in a productive, meaningful, and effective way.
- Preventing Restraint and Seclusionā Chapter 9 offers historical and current perspectives on seclusion and restraint (S/R) with children and adolescents, discusses the dangers associated with these interventions, and reviews a strategic framework to prevent their use. In addition, key youth and family roles in innovative S/R reduction approaches and effective pragmatic resources to facilitate practice change are provided.
- Working With Youth in Transitionā The transition to adulthood is a continuous process of rapid psychosocial change that starts accelerating at age 16 and only begins to slow considerably in the late 20s. Chapter 10 describes the unique needs of youth in transition as well as innovative approaches to supporting the transition to adulthood for youth who have serious mental health conditions and are receiving residential interventions.
- Promising and Best Practices in Medicationā Chapter 11 will summarize the research and concerns regarding the use of psychotropic medication for children and adolescents, address research and issues specific to residential programs, discuss youth and family involvement in decisions about the use of medications, and identify best practices in the use of psychotropic medication during residentia...
