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VALUES OF THE WRAPAROUND PROCESS

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VALUES OF THE WRAPAROUND PROCESS Powered By Docstoc
					        Orientation to
Child and Family Team Practice
            and the
Pennsylvania Youth and Family
           Institute

           Jim Rast, Ph.D.
       John VanDenBerg, Ph.D.
          December, 2007


                                 1
          This Pennsylvania Effort…
   Pennsylvania has a long history of successful
    collaboration and programs to support children and their
    families.

   Through the PYFI, VVDB is committed to developing
    capacity to provide, coach and train sites with a
    commitment to implementing Child and Family Teams
    processes (high fidelity wraparound) in PA

   VVDB is partnering with the PYFI, participating Counties,
    and State Level partners to help this transformation
    succeed

                                                           2
                Wraparound
 Wraparound and wraparound are not the
  same thing.
 PA uses the term wraparound differently
  than almost every other state.
 Arizona had other uses for the term
  wraparound and chose to use the term
  ―child and family teams‖ to describe the
  process of integration and individualization
  used at the practice level

                                                 3
      Development of Wraparound
Grassroots Development
 General Principles
 Applied in many different ways
 Creativity and advances
 200,000 children in 1999


Initial Results
 Life changing success stories
 Strong support
 Mixed evaluation results
 Research shows results match fidelity
                                          4
             Defining Wraparound

   Steps to Define Wraparound
     Duke meeting on principles
     National Wraparound Initiative
         Who they are
         Process used

         Products produced

       Wraparound Fidelity Assessment System



                                                5
         Wraparound Process
Is a Process for Supporting Youth and
  Families that
 Is defined by 10 principles of how the
  process is implemented;
 Is done in four phases and related activities
  that describe what is to be done; and
 Fits the four components of the theory of
  change that explains why it works.

                                             6
             Principles for Wraparound


   Family Voice and        Culturally Competent
    Choice                  Individualized
   Team Based
                            Strengths Based
   Natural Supports
                            Persistence
   Collaboration (and
    Integration)            Outcome Based and
   Community Based          Cost Responsible



                                                    7
Phases and Activities, and Skill Sets
   NWI phases and activities
   Vroon VanDenBerg specific skill sets for
    wraparound facilitators, coaches and family support
    partners
   VVDB performance based training and coaching
    products
   Credentialing and Quality Improvement
   Used and been in over 35 sites across North
    America.
   Sites using these products report greatly improved
    outcomes and more satisfied families and staff.


                                                          8
                         Impact on CAFAS Scores
                         after 6 Months
                                                    6 months
Chnage In CAFAS Scores




                         10
                          0
                         -10
                         -20
                         -30
                         -40
                         -50
                               Trad MH Services   High Fidelity   Low Fidelity then
                                                  Wraparound         Coaching


                                                                                      9
                                        Impact of Fidelity

                                     Overall                                        Low Fidelity       High Fidelity

                    4.0                                                     4.0
                    3.8                                                     3.8
                    3.6                                                     3.6




                                                        Average FRS Score
Average FRS Score




                    3.4                                                     3.4
                    3.2                                                     3.2
                    3.0                                                     3.0
                    2.8                                                     2.8
                    2.6                                                     2.6
                    2.4                                                     2.4
                    2.2                                                     2.2
                    2.0                                                     2.0
                          Intake   6 Months 12 Months                             Intake    6 Months     12 Months
                                                                                                               10
                                               Average Fidelity Score
                      Vo
                        ic
                          e
                               an
                                  d
                                      C




                                                     0.1
                                                     0.2
                                                     0.3
                                                     0.4
                                                     0.5
                                                     0.6
                                                     0.7
                                                     0.8
                                                     0.9




                                                       0
                                                       1
                                         ho
                    C                        ice
                       om CF
                            m            T
                 C             un eam
                   ul
                      tu            ity
                         ra
                            l C Ba
                                 om sed
                                      pe
                             In          te
                                di          n
                                   vid ce
                       St               ua
                          re              liz
                              ng
                                  th          ed
                       N              s
                          at            Ba
                 C            ur
                                 al         se
                    on
                        tin          Su d
                            ua           pp
                                tio         or
                                    n          ts
                                                                    Low Fidelity




                                       of
                              C           C
                                ol           ar
                                   la           e
     Principle                        bo
                                         ra
                              Fl            tio
                                 ex
                        O             Fu n
                          ut             nd
                                                                    High Fidelity




                              co             in
                                  m            g
                                     e
                                        Ba
                                           se
                                               d


                                      O
                                                                                    Breakdown of Fidelity Scores




                                          ve
                                             ra
                                                ll
11
                         Impact on CAFAS Scores
                         after 18 Months
                                                  6 months   18 months
Chnage In CAFAS Scores




                          10
                           0
                         -10
                         -20
                         -30
                         -40
                         -50
                         -60
                         -70
                               Trad MH Services      High Fidelity       Low Fidelity then
                                                     Wraparound             Coaching


                                                                                             12
        The Theory of Change is

 Is why we do wraparound
 Is what about wraparound that makes it
  work
 Is what differentiates it from other service
  coordination processes
 Defines expectations for what we hope to
  accomplish through wraparound

                                                 13
Theory of Change for Wraparound
        Why Does Wraparound Work?

                  Self

               Efficacy
               NEEDS

               Efficacy
                Natural
                Support
                System

             Integrated Plan




                                    14
Theory of Change for Wraparound
        Why Does Wraparound Work?

                  Self                 Wraparound
                                      addresses the
               Efficacy
               NEEDS                  priority needs
                                    identified by the
                                    youth and family
               Efficacy
                Natural
                Support
                System

             Integrated Plan




                                                  15
    Families are not Fully Engaged
Research finds that
 Up to 60% of families drop out of services before
  they are finished
 Children from vulnerable populations are less
  likely to stay in treatment




                                                 16
The Challenge of Full Family Engagement
    Why do families drop out?
      Treatment is stressful
      Treatment seems irrelevant
      Poor relationship with therapist
      Concrete obstacles:
         Time, transportation, child care, other
          priorities




                                                    17
Wraparound Supports Engagement
   Addresses family prioritized needs
   Plans for needed support
   Family-centered and youth guided
   Culturally competent
   Strengths- and community based
   Creative and Individualized
      Teams brainstorm how to mobilize
       professional, natural, and community supports
       to meet unique needs
                                                   18
       Theory of Change for Wraparound
                     Why Does Wraparound Work?

   Wraparound                  Self
strengthens youth
   and families             Efficacy
                            NEEDS
 confidence that
 they can create
positive change in          Efficacy
    their lives
                             Natural
                             Support
                             System

                          Integrated Plan




                                                 19
                      Self-Efficacy
   is the belief in one’s capabilities to organize and execute
    courses of action required to produce given attainments
   plays the central role in the cognitive regulation of
    motivation

   People with high self-efficacy are more likely to expend
    more effort, and persist longer
   Low self-efficacy often results in poor task planning, as
    well as increased stress.
   people with high self efficacy often take a wider picture
    of a task in order to take the best route of action



                                                                20
Theory of Change for Wraparound
        Why Does Wraparound Work?

                  Self                 Wraparound
                                     strengthens the
               Efficacy               social support
               NEEDS                system that helps
                                      the youth and
                                      family succeed
               Efficacy
                Natural
                Support
                System

             Integrated Plan




                                                  21
         What or Who are Natural Supports

   Natural supports are community resources available for
    use by youth and families within which are consistent
    with their cultural beliefs and practices.
   Natural supports may involve individuals outside the
    immediate family and a variety of informal supports
    found in the neighborhood or larger community.
   Natural resources are external to the child and family
    and, once accessed through active affiliation, become
    part of the child's and family's strengths.




                                                             22
Research on Impact of Natural Supports
   positively   impact chronic disease related health
    behaviors
   increase compliance to routine medical care
   improved health for older people with chronic
    conditions
   decrease postnatal depression for new mothers
   decrease depression in older women
   positive natural supports decrease drug use
   positive natural supports decrease HIV risk behaviors
   decrease punitive punishment from parents
   increase coping, resilience and sustainability for
    caregivers
                                                         23
   What Natural Supports Do for
           Caregivers
Natural Supports may support and influence
improved and sustained care-giving by
   Creating   situations to observe and learn about
    effective parenting from people the family trusts
   Providing a sense of attachment and someone
    to talk to during tough times
   Someone to trust and provide respite from
    many types of demands of care giving
   Providing access to resources and material
    goods
   Providing coping resources


                                                        24
Theory of Change for Wraparound
        Why Does Wraparound Work?

                  Self
                                      Wraparound
               Efficacy
               NEEDS
                                      creates an
                                    integrated and
                                    simplified plan
               Efficacy              for the whole
                                         family
                Natural
                Support
                System

             Integrated Plan




                                                 25
Seriousness of the Problem

Prevalence of Serious Emotional Disturbance (SED)

Population Proportions
(9 to 17 year-olds)

5-9% Youth with SED &
     extreme functional
     impairment
9-13% Youth with SED,
     with substantial
     functional impairment
20% Youth with any
    diagnosable disorder



                                                    26
                              Children with Behavioral Health
                              Disorders Across Systems

                       100%                       None   Child Welfare   Juvenile Justice
Percent of Children




                                                 100%
                        80%
                                                  90%
                        60%              None     80%
                                         BH Dx    70%
                        40%              SED      60%
                                                  50%
                        20%
                                                  40%
                         0%                       30%
                                                  20%
                              uc F
                               TA e


                                     n
                              Ju e
                                   ic


                                  io
                            Ed N
                            le ar




                                                  10%
                                st


                                at
                          ni elf




                                                   0%
                        ve W
                      Ju ld
                         hi
                        C




                                                                                       27
     Fragmented System

     Yet, for too many Americans with mental illnesses, the
     mental health services and supports they need remain
     fragmented, disconnected and often inadequate,
     frustrating the opportunity for recovery. Today’s mental
     health care system is a patchwork relic—the result of
     disjointed reforms and policies. Instead of ready access
     to quality care, the system presents barriers that all too
     often add to the burden of mental illnesses for
     individuals, their families, and our communities.

                            Michael F. Hogan, Ph.D. 2003 Chairman
             President’s New Freedom Commission on Mental Health

28
                Tyler Family

   Marge, 38   Major Strengths, Family Culture:
   Evan, 39     Parents married 17 years

   Billy, 14    Marge’s parents alive and in the area, care
                  about the family
   Sam, 12
                 Marge has entrepreneur skills in area of
   Sally, 12     home cleaning business
                 Family has history of surviving adversity
                  using their wits
                 Evan has over a year of sobriety after a
                  decade of untreated alcoholism
                 Children provide active support to each
                  other
                 Family culture prioritizes educational goals
                 Billy knows what ―cool‖ is
                                                                 29
      Major Needs of Tyler Family
From the more detailed description of the Tyler
family list concerns or risk factors




                                                  30
    Major Needs of the Tyler Family
Billy:                                   Evan:
 Serious Juvenile Justice involvement    Verbally and physically
 Breaking and entering, shoplifting,      abusive to children
    thefts of all types                   unemployed, unable to
 Two years behind in school but lots of   hold job due to self
    potential                              described ―Stubborn
                                           attitude about authority‖
                                          Recovering from severe
Twins (Sam and Sally):
                                           alcoholism
 Bi-polar, extreme mood swings.
 In child welfare custody in a
    specialized foster home              Marge:
                                          Family history of major
 School is having problems controlling
    behaviors and engaging them in         depression (untreated);
    lessons                               Suicidal ideation which is

 All school behavior plans have failed,
                                           likely to result in death.
    and school is suggesting home bound
    instruction
                                                                   31
                 Pairs Activity

   After the concerns and risk factors for the
    Tyler family are discussed brainstorm
    typical services and plan(s) for them in
    your county. We are going for typical –
    what the average youth and family in their
    situation would get.



                                              32
Typical Plans for Tyler Family




                                 33
     How complex is the Tyler Family?

   Based on initial information, rate this family from
    one to ten, with one being least complex needs
    and ten being most complex needs….

   What don’t you see that would make this family
    rate a higher number?




                                                      34
          26 Helpers and 12 Plans
School (5)                     2 IEPs (Sally and Sam)
Technical School (2)           Tech Center Plan
Child Welfare (1)              Permanency Plan
Juvenile Justice (1)           Probation Plan
Children’s Mental Health (6)   3 Children’s MH Tx Plans
Adult Mental Health (3)        2 Adult MH Tx Plans
Employment Services (2)        Bailey Center Plan
AA (1)                         Employment Services
Housing Department (1)
Bailey Center (2)              33 Treatment Goals or
Specialized Foster Care (2)      Objectives

                                                          35
Collaborative Efforts in Tyler’s Town
1.   Local Judge is chairing a restorative justice effort to address
     truancy and violence in schools. Juvenile Justice and law
     enforcement has major presence in local High Schools.
2.   School Superintendent and United Way are leading an
     interagency effort for substance abuse prevention.
3.   Local Health Department has a grant and steering
     committee to decrease teenage Pregnancy.
4.   Child Welfare has a mandated interagency coalition that is
     planning for multi-agency involved children and youth.
5.   Children’s Mental Health has co-located staff at child welfare
     supporting family preservation and family group decision
     making.
6.   Adult Mental Health and Adult Addictions Services are in
     same agency.
7.   There is a grassroots effort to develop more church
     involvement in supporting children and families.
                                                                  36
              Your Collaboration
   Is your communities more, the same, or
    less collaborative than the Tyler’s town?




                                                37
           Current Services to Tyler Family
   School has IEP for each of the           Juvenile Justice has just released
    twins and extensive behavior              Billy from detention over breaking
    support and planning.                     and entering, Billy has new charges
   Billy is in a tech center but is          of theft,
    rarely in school, school has             Court ordered therapy
    offered many adaptive plans but          Restitution supervised by local
    none have worked.                         youth services agency with a
   Both schools call parents                 counselor and mentor
    frequently.                              Housing is trying to find safer
   Child welfare has substantiated           housing
    Dad’s abuse of twins, has                Marge sees a psychologist
    removed them from the home,               occasionally in crisis times and has
    created a strict reunification plan       been referred to a psychiatrist, went
    that includes family therapy and          once but does not want to go back.
    supervised visits                        Evan goes to four AA meetings a
   Twins are in specialized foster           week and sees his sponsor twice a
    care with care and a therapist who        week, calls daily
    supports the foster parents.             Evan goes to court ordered anger
   Twins are in therapy, two different       management
    therapists and a psychiatrist            Evan is working with Vocational
   TSS to help out with Billie               Services on employment skills

                                                                               38
Monthly Appointments for the Tylers
Child Welfare Worker                                     1
Marge’s Psychologist                                     2
Marge’s Psychiatrist                                     ?
Billy’s therapist                                        4
Billy’s restitution services                             4
Appointments with Probation and School                   2
Family Based                                             4
Therapeutic Support Staff                               12
Evan’s anger management                                  4
Children’s Psychiatrist                                  1
Other misc. meetings:, Housing, Medical                  5
AA Meetings                                             16


Also, consider daily schedule (School, tech center, and vocational
   training) and the dozen or more calls from the schools each month.
                                                                    39
           Comments from the Files:
   Parents don’t respond to school’s calls
   Family is dysfunctional
   Parents are resistant to treatment
   Home is chaotic
   Billy does not respect authority
   Twins are at risk due to parental attitude
   Mother is non-compliant with her psychiatrist, does not
    take her meds
   Father is unemployable due to attitude
   Numerous missed therapy sessions
   Attendance at family therapy not consistent, recommend
    group therapy for parents


                                                          40
            Mutual Perspective

How do the              How does the family
 professionals involved  view the
 with the Tyler family   professionals? Does
 view this family, and   the family feel that
 their role in the       they are asking for
 family? Do they see     help? Does the family
 their role as           want the same help
 ―Rescuer‖ ―Stabilizer‖  as the help the
 ―Enforcer‖              professionals want to
 ―Supervisor‖            give?
 ―Teacher‖?
                                             41
Help isn’t help unless it is
       asked for!*
 Sometimes people need help even though they don’t
ask for it. How can we engage them in a way that helps
  them trust us when we see a need that they do not
 see? Will any plan work if the Tylers are not on board
              or don’t see the plan is theirs?

   *Quote from Help: The Original Human Dilemma
    (pub. By Harper, 2004), author is Garret Keizer




                                                          42
                              Cost
Specialized Foster Care
Psychiatrist
Psychologist
Therapy (Individual and Family Based)
Therapeutic SS
Tech Center
Vocational Training
School
Restitution

Per Month

  Plus the cost of the salaries for the public staff and the time from AA.
  If there is a crisis, detention, or higher levels of care the cost goes
  up considerably

                                                                      43
Going From Collaboration to Integration
          is a Needed Shift

Collaboration: Agencies are familiar with each
  other’s missions and roles, key staff work
  with each other at the child/family level, but
  retain single system decision making power
  and planning.
Integration: Agencies are familiar with each
  other’s missions and roles, key staff work with
  each other at the child/family level, sharing
  decision making in a team format that
  includes the family, producing a single plan
  that meets all system mandates and that is
  owned by the entire team.                       44
            Rate your town…

 On collaboration, rate your town from one
  to ten, with ten being most collaborative?
 On integration, rate your town from one to
  ten, with ten being most integrated?
 If ratings were different, what are non-
  blaming or shaming reasons for the
  differential ratings? For example, staff may
  not be trained to integrate.
                                             45
           First: Crisis Stabilization

   Before team building, stabilize immediate crises with
    safety plan for Billy’s criminal behavior, Marge’s suicidal
    behavior and maintenance of Evan’s sobriety
   Crisis planning involves prediction of worst case
    scenario, functional assessment to target plan on
    function of crisis behaviors, implement individualized,
    strengths-based, culturally competent prevention efforts,
    and plan for what to do if crisis occurs




                                                              46
         Initial Tyler Wraparound Team
   All of the immediate family (5)
   Marge’s Parents (2)
   Twin’s behavioral staff from school
   Probation Officer
   Child Welfare Case Worker
   Marge’s business co-owner
   Evan’s AA Sponsor
   Care Coordinator
   Family Support Partner

14 total, team can change over time…

Later, teachers, therapists, vocational staff, others in consulting roles

                                                                            47
                   Next, Prioritize Needs and Plan
     Notice that needs are addressed in sequence with integrated
      approach to selection of need priority, with family in control
                  of final decisions with court approval
1.   Billy’s thefts – highly individualized plan using the ―cool‖
     grandfather to help stop criminal behavior, do individualized
     restitution to victims, and build on Billy’s strengths
2.   Support of twins and highly individualized plan to gradually move
     toward reunification, done at approximately same time as #3 so
     that school, foster home, and home are consistent
3.   Plan to stabilize twin’s school behavior using Marge,
     grandparents and others as volunteer aides, including accelerated
     plan to get Billy up to grade level using volunteer aides who are
     ―cool‖
4.   Support Marge’s business efforts to keep income rolling in
5.   Continued Vocational Services for Evan, with team support of job
     finding

And so on, over a year (predicted)


                                                                       48
Benefits of an Integrated Approach for the Tyler Family
                     and the Town

   Tyler family has real hope from their plan and process,
    have more energy each time a goal is met.
   The professionals involved get to maximize the use of
    their own expertise. For example, which plan would you
    rather be the psychiatrist in? Or the teacher?
   The professionals get to practice integration skills which
    will benefit 1000’s of other families, trading control and
    autonomy for outcomes at the family level, and more
    satisfying jobs. Also may decrease professional turnover.
   Taxpayers get return for their investment
   Potential multi-generational positive effect
   Community building a family at a time.

                                                           49
                   Cost

Not why we are here, but the real five year
  cost of Tylers was in excess of $250,000 –
  real money paid by real taxpayers
Is the ―typical plan‖ a good deal for
  taxpayers?




                                           50
                        Permanency
                                          Comparison          DHS Wrap


                             70%

                             60%
in Permanency Setting
                             50%
   Percent of Youth




                             40%

                             30%

                             20%

                             10%

                              0%
                                    B1    B2     1       2        3
                        Comparison 23.5% 20.6% 14.7% 20.6% 26.1%
                        DHS Wrap   5.4% 13.5% 32.4% 43.2% 65.2%
                                          6 Month Intervals


                                                                         51
                           THE Placement
   The most important part of finding the placement is really getting to
    know the strengths, culture and needs of the youth.
      Talk to the youth at length and also talk to people who know the youth
       (caregivers, former caregivers, teachers, etc)
      Strengths include people who might provide some level of support
      Needs focus on what it will take in an environment to be successful for
       the youth and what the youth wants out of life
      Needs include the challenges that make the youth hard to place
   Once you know the youth use the information to match to THE
    placement
        Use the strengths to sell the youth to the placement
        Be very honest about the challenges and needs so placement knows
         what to expect
        Plan with the youth and placement before the youth arrives so the initial
         experience is better
        Frequent communication and support over time to youth and placement
         once there
   In the meantime
        Stall
        Use the same principles and keep working on the THE placement if a
         temporary stop is required
                                                                                 52
            Youth Story - THE Placement
   Youth was 16 and in lock down for shoplifting and AWOL from TFC.
    History of sexual abuse and had become sexually reactive. Multiple
    failed placements because of sexual and aggressive to other kids.
    No supports or visits for several years.
   Strengths – good with adults, motivated to succeed
   Challenges – around younger kids or kids in home, learning
    disability requires very structured situation and instructions
   THE placement – a mature couple with no other children in the
    home
   The Results – found grandmother and brother who want to support
    him but could not provide placement. Developed long range vision
    of work with need for supported living. Completed school and went
    to Job Corp. Will return to live with grandparents supported by
    brother until he is ready to go out on his own.




                                                                     53
Stability of School Placement
                                                      Baseline   6 Months


   Average Number of Schools per Six Months
                                               2
                                              1.9
                                              1.8
                                              1.7
                                              1.6
                                              1.5
                                              1.4
                                              1.3
                                              1.2
                                              1.1
                                               1
                                                    Control         Wrap

                                                                            54
                               Summary of Results
                                                                 Positive
                   Outcome (Data Source)                                     Comp      DHS Wrap     NC Wrap
                                                                 Direction
Average Number of Days in Permanency Setting (KIDS)                             7         92*          63*

Percent of Youth in Permanent Placement 12 to 18 months (KIDS)                4.1%      55.7%**      29.5%*

Change in Number of Residential Moves per Six Months (KIDS)                   + 0.7      - 0.6*        0

Number of Schools in Six Month Period (Caregiver Survey)                       2.0        1.2*         1.4

Changes in Restrictiveness of Living Scale (KIDS)                             + 0.7     -1.26**       -.32*

Change Level of Family and Caregiver Stress (Caregiver Survey)                + 4.4      - 6.0**      + 3.6

Change in Level of Youth Problems (Ohio Scales)                               + 1.3      - 5.8**      +1.8

Change in Level of Youth Functioning (Ohio Scales)                            - 5.2     + 3.0**       - 1.1

Change in Level of Impairment (CAFAS)                                         - 11.4    - 25.0**      -10.5

Reduction in Medicaid Spending (OHCA)                                        $75,383   $400,906**   $222,384*




                                                                                                       55
                         Impact on Medicaid Spending
                                                 Control   DHS Wrap

                          100,000
Change from Baseline Per Period

                                  0
     Medicaid BHS Cost




                      -100,000


                      -200,000


                      -300,000


                      -400,000


                      -500,000
                                        1        2               3        Total
                   Control            56,837   -10,604        -121,616   -75,383
                   DHS Wrap           35,711   -97,580        -339,037   -400,906

                                                                                    56
Facilitator Credentialing using VVDB
               tools…
   Novice -- has completed 24 hours of class room
    (or E-Learning) instruction, in-class behavioral
    rehearsals, pre and post tests, and 20 hours of
    shadowing
   Practitioner -- has a professional development
    plan, is receiving appropriate supervision and
    coaching, and has demonstrated competency
    using VVDB documentation and observation
    review tools.


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      VVDB Observation and Review
                Tools
   Either the Supervisor/Coach or Coach actively
    reviews document products and observes key
    activities based on NWI Phases and Activities
   Documentation Reviews: SNCD; Wrap Plan;
    Functional Assessment; Crisis Plan; Progress
    Notes; Transition Plan
   Observation Reviews (live): Initial Engagement
    meeting; Initial Team Meeting; Follow-up
    Meeting

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          Barriers to High Fidelity
            Wraparound in PA
1.   In small groups, assign a recorder with good
     hand writing (the notes will be turned in)
2.   Begin the discussion by introductions. Then,
     list out top barriers which may get in the way of
     implementing wraparound as defined by the
     National Wraparound Initiative (30 minutes)
3.   Prioritize the list and choose the top barrier (5
     minutes)
4.   Then (most important) make a
     recommendation for removing the top barrier.
     (10 minutes)
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            Remember one thing…

   High Fidelity Wraparound is a process of
    integration for children and families with co-
    occurring disorders. It is specifically designed to
    lead to positive clinical outcomes and is based
    on a theory of change
   In general, the field has greatly underestimated
    the complexity of doing a good job with
    wraparound at the supervisor and staff levels.


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