TCOM Supervision for CANS-NY Suzanne Button Ph D

TCOM Supervision for CANS-NY Suzanne Button, Ph. D & April Fernando, Ph. D • Chapin Hall at the University of Chicago

TCOM and Clinical Supervision v Understand the TCOM framework as it applies to the role of the supervisor, v Understand the importance of organizational culture and “buy-in. ” v Develop a map for supervising to effective use of the CANS-NY in support of TCOM. v Develop a toolkit of supervisory strategies across the TCOM continuum.

A Philosophy from Which Change Can Grow Transformational: Our work is focused on personal change. Collaborative: We must develop a shared understanding and vision. Outcomes: What we measure is relevant to the decisions we make about the strategies and interventions we use. Management: Information gathered is used in all aspects of managing the system from planning for individuals and families, to supervision, and program/system operations. t o c m

TCOM Decision Points and the Role of the Supervisor Shared Vision Communimetrics Access Engagement Service Appropriateness Service Effectiveness Linkages Development & Culture TCOM Supervision The Supervisor can use the CANS-NY to facilitate transformation and collaboration at each point along this continuum.

Organizational Context • Developing a learning organization involves changes in attitudes, practices, and structures. Risk-taking behavior is essential in the context of any change, providing lessons are learnt from the successes and failures of these behaviors and incorporated into future structures. • Leaders of change have to be an integral part of the clinical team and be adequately supported with basic resources, such as personnel, time, and other facilitative mechanisms. • A responsive organizational culture is a prerequisite to embedding sustainable initiatives

Change?

The Transformational Power of Supervision Supervisors have a critical leadership role in operationalizing and supporting cultural change. For TCOM: Supervisors are key in determining whether the CANS-NY remains a tool that is given, or is a strategy that helps clients and providers collaborate and communicate, and supports tracking personal change and transformation. Need to reclaim the supervision hour as one for consultation, support and training. Using a competencies approach in teaching TCOM helps to identify the knowledge, skills, attitudes, and behaviors that are needed to facilitate personal change. 7

Engaging in Transformation – Creating “Buy-in” What specific needs do the clients in your program have and how can their needs be addressed more effectively with this common metric? Who among your staff does NOT want to see clients improve in school, reduce risk behaviors, feel reinforced by the knowledge that, for example, you are helping clients build skills for a full rich life in your work across the organization? Who among your staff has not been frustrated by the absence of adequate discharge resources to maintain gains? 8

SUPERVISION C-A-T-AP-ULT Treatment Planning Context Attending to Progress Assessment 9 Adapted from San Francisco County’s Family Driven Supports: Families Teach Best Practices in Assessment

Supervision C-A-T-AP-ULT • • • Highlight client/family experiences and context. Identify effective practices for engaging families. Teach a strengths-based approach. Context Adapted from San Francisco County’s Family Driven Supports: Families Teach Best Practices in Assessment

GOAL: COLLABORATION, COMMUNICATION, TRANSPARENCY AND SHARED VISION

Engagement: Negative vs. Positive Interactions • Coming into interactions with assumptions about client, family/caregiver. • Be aware of biases and prejudices. • Failing to explain the reason for each aspect of treatment (assessment, plan, participation, documentation, intervention). • Validate participatory role of clients in all decision making about their lives. • Not sharing what is written about the client; sharing information in a “blindsiding • Be consistent, reliable, honest. Fully disclose. Transparency. • Approaching interactions as doing things to or for the client/family rather than supporting them in doing things for themselves. • Honor all differences. All differences.

Understanding and Honoring Differences Family Life Cycle Ideals • Meanings • Timings • Transitions CULTURAL DIVERSITY (values, beliefs) • Family Organization Nuclear/Extended Family • Connections • Hierarchies • Communication Styles •

Understanding Ourselves and Others Ecological Context Community • School • Work • Religion • SOCIAL JUSTICE (discrimination, racism) Migration/Acculturatio n Separations & Reunions • Trauma • Disorienting Anxieties • Cultural Identities •

Family Life Cycle Ecological Context • Ideals • School • Meanings • Work • Timings • Religion • Transitions Clinician’s Maps SOCIAL JUSTICE (discrimination, racism) Migration/Acculturation FAMILY MAPS Personal Theory Supervisor’s Maps • Separations & Reunions • Trauma • Disorienting Anxieties • Cultural Identities Latino Families in Therapy (2 nd ed. , p. 38) by Celia J. Falicov, 2014, New York, NY: Guilford Press. CULTURAL DIVERSITY (values, beliefs) • Community Family Organization • Nuclear/Extended Family • Connections • Hierarchies • Communication Styles Multicultural and Multi-layered

HOLDING THE CULTURAL CONTEXT A HUMBLE APPROACH TO RESPONSIVE AND RESPECTFUL CARE It is beneficial to understand cultural competency as a process rather than an end product. Competency involves more than gaining factual knowledge — it includes our ongoing attitudes toward both the people we work with and ourselves. Cultural Humility The ability to maintain an interpersonal stance that is otherorientated (or open to the other) in relation to aspects of cultural identity that are most important to the person. Cultural Responsiveness The ability to learn from and relate respectfully to people from your own and other cultures.

Supervision C-A-T-AP-ULT Assessment • • Teach strategies for a collaborative assessment experience. Teach a process emphasizing clients & families participation, review and finalization of assessment. Adapted from San Francisco County’s Family Driven Supports: Families Teach Best Practices in Assessment

• Why assess? • Why CANS-NY? • Why collaboratively?

Information Science Principles Relevant Items are included because it is relevant to supporting decisions for individuals. Actionable Level of need or strength translates to action. Provides a way to gauge the immediacy/intensity of effort currently needed. Timely Items are rated within a 30 -day window. This helps to keep the assessments current. Action levels can override the 30 -day window. 04 02 03 Client Focus 05 01 The ‘What’ 06 It’s about the individual, not the individual in services. Focuses on the extent to which the individual can function without services or intervention. In assessment, focuses on what the individual’s needs. Avoids explaining away needs with what might be underlying causes. The ‘why’ is brought into treatment planning. Culture and Development and culture are considered before rating the items. Shared Vision Principles

Teach a Strengths-Based Approach BUILDS TRUST Models respect and kindness towards children, youth and families. EMPOWERING Conveys our belief in our children and families to continue healthy development and make changes when needed. HOPEFUL Conveys high expectations of individuals and families to address areas of challenge.

The Collaborative Assessment: Part of a Larger Process 1 1 2 2 3 4 4 TRACK PROGRESS IDENTIFY SET FUNCTIONAL IDENTIFY RESOURCES NEEDS & STRENGTHS GOALS & INTERVENTIONSGIVE FEEDBACK 6 5 6 MAKE PLAN CELEBRATE ADJUSTMENTSACCOMPLISHMENTS

The Collaborative Assessment: Overview Assist with planning and structuring a comprehensive assessment. TCOM requires a lot of front-end work. Confirm they have the necessary content knowledge before beginning the process with the individual or family. Some tips from clients and families: • Reassure us that we’ve done the right thing by coming in (lead us where we can get what we need). • Tell us a little bit about who you are (No robots) … and your work with families like mine (No freaking out, thinking I am/my child is the worst one). • Be clear about the supports you can offer. • Tell us who will see the assessment.

Supervising the Collaborative Assessment: CANS Spend time practicing how each domain will be introduced; go over potentially challenging items. Help staff identify a process to resolve disagreements in rating items, and how to handle situations when a consensus regarding a rating is not possible. Help clinician in writing the assessment in client/family friendly language and being transparent. Prior to presenting the assessment and CANS-F to the family, review ratings and practice how to discuss the assessment. When reviewing strengths, begin to operationalize each strength for the individuals and family: How does the strength serve the individuals and the family? In discussing needs, begin to prioritize needs and identify patterns: Do any underlying needs emerge?

Assessment: Hot Spots to Supervise “What if family members or the treatment team disagrees about ratings” Practice reframing issues and focus on functioning and action required to address functioning. Rate as an average of the scores. “What if I’m receiving conflicting information? How to I rate the item? ” Use best clinical judgment (e. g. what intensity of action makes the most sense? what will benefit the client the most? ). Consider assigning a ‘ 1’for “watchful waiting. ” Adapted from San Francisco County’s Family Driven Supports: Families Teach Best Practices in Assessment

Collaborative Assessment: Supervision Strategies • Does the supervisee bring the CANS-NY to supervision? • Do supervisor and provider agree on scoring of the CANS-NY? Given the verbal description of cases in supervision are the scores valid: too high or too low? • Were there any items on the CANS-NY the provider struggled to score for this client/family? • Is all pertinent information discussed in supervision reflected in the CANS-NY? • Did the client have any elevated scores in domains that would indicate unique needs (e. g. trauma domain)? • Have the CANS-NY scores been shared with the client and caregivers? Why not? or how did this go? Adapted from Using the CANS in Working with Complexly Traumatized Children and Adolescents: Creative Applications for Different Professional Roles

Supervision C-A-T-AP-ULT • • • Teach strategies for creating a collaborative treatment plan. • Teach a process for consistent monitoring of the treatment plan. Teach strategies for creating a collaborative treatment plan. Teach a process for consistent Treatment Planning monitoring of the treatment plan. Adapted from San Francisco County’s Family Driven Supports: Families Teach Best Practices in Assessment

[Shared Understanding of Problem and Goals] [Useful Strengths] • • What CANS-F needs and/or strengths items must be addressed to address the invention goal? CANS-F Domains: • Caregiver Functioning • Child Functioning What CANS-F items representing the family’s function will change because of addressing the treatment target needs? CANS-F Domains: • Family Functioning • Caregiver Advocacy What activities/interventions/resources are needed to address the treatment target needs? What identified strengths can be useful to support the work on the treatment target needs?

Foundational ”Why Wheel”

TREATMENT PLANNING: Hot Spots to Supervise “What if family members disagree about whether an item requires intervention? ” Practice reframing issues and focus on functioning. “What items do I present to families? ” Practice linking CANS-NY items to the shared understanding of the problem, and then to the treatment target needs and functional goals. This will help identify which items to prioritize and address. “What if there are too many 2 s and 3 s? ” “How do I know what to prioritize? ” Help the clinician identify strategies that will help translate items into treatment goals and objectives (e. g. , shared understanding of the problem) Adapted from San Francisco County’s Family Driven Supports: Families Teach Best Practices in Assessment

Treatment Planning: Questions for Supervision • Do CANS-NY ratings drive the treatment plan? How or why not? • What has been done to address safety and other priority concerns that may be related to unique needs? • Are there other key people in this family’s life that can assist in addressing any of the familys needs or building their strengths (community/natural supports, other professionals)? • Has psychoeducation been provided with the youth, caregivers, school, or other involved providers to assist them in understanding (and managing) the youth’s behavior? • When applicable, has there been attention given to the caregiver section of the CANS-NY to identify the areas for building family resilience? • Has the counselor identified all actionable items and usable strengths and incorporated these into service plan outcome/goal statements? • Before signing off on any significant decisions, has the CANS-NY been reviewed to determine if the scores support placement or other decisions (e. g. return home, residential placement, etc. )?

Supervision C-A-T-AP-ULT Attending to Progress • • Adapted from San Francisco County’s Family Driven Supports: Families Teach Best Practices in Assessment Practice using CANS-NY in communication with youth and family. Use CANS-NY data as feedback on intervention impact and to monitor progress.

Management of service delivery – from individual service levels to goal setting to LOS to census management to program evaluation to agency evaluation should actually be linked to and driven by the measurement of meaningful and salient clinical variables

Framework for Attending to Progress with the CANS-NY Assess Collaboratively Plan Monitor • Collaboratively defined needs and strengths • Identify key areas in need of change • Develop a plan that incorporates all views. • Implement plan that all understand agree to • Determine interventions and supports • Attend to changes in action levels for needs and strengths Optimize • Change plan in the absence of progress. Celebrate • Punctuate – and celebrate – success at all levels. .

Group Supervision: TCOM Application Case Conference Prior to the conference, review the following: • How collaborative was the treatment planning process? • What are the identified needs? strengths? • What are the functional priorities of the client/family? involved stakeholders? other providers? (What outcomes would each like to achieve? ) • What treatment/interventions/services have been tried? At the conference: Realign thinking with TCOM and CANS-NY: • What functional goals do all agree upon? • What does the evidence say about effective approaches to address these priorities? • What other assessment tools are present? How collaborative are they? What do they say? • What resources does our system have? Does the client/family have access to these needed resources?

TCOM Case Conference: Revisit Progress Restructure or “tweak” the plan. Identity barriers and resources for the clinician to accomplish the changes in the service. Decide on a time frame for follow-up. In the interim…. Coach clinician and provide scaffolding as needed during the duration of new plan pilot (e. g. , resources, supervisory coaching, internal or external experts). Group reconvenes at end of agreed upon time period. Assess the outcome at the end of follow-up; revise plan accordingly. Generalize findings of this experience: What would the group/program change with regard to what was learned from TCOM and the CANS-NY? How can this be done?

Attending to Progress: Program Level Identify patterns of success to understand emulate, and identify areas to act on and improve. Find a way to build services based on both clinical experience and clinical science. Identify training / supervision needs.

Supporting Continuous Quality Improvement at all Levels Are we managing transformation? Identify reports that can help staff, clients and families better track progress. Develop process of having CANS-NY data integrated into supervision, case conference, and sessions with clients/families. Review clients’ needs and strengths data; review treatment plan outcomes and interventions. Making meaning: Identify patterns in the data and actions needed.

Attending to Progress: Provider or Program Level WHAT IF WE AREN’T MAKING PROGRESS? Practice discussing CANS-NY as outcome metrics: Does the plan need to be changed in light of the data? What about the strategy or interventions linked to the CANS-NY items worked or did not work? What about the strategy or intervention needs to be changed? Graph from: TCOM Report Suite — Minimum Standards for Vendors and Systems (Israel, 2015)

Attending to Progress WHAT ELSE MIGHT BE GOING ON? When looking at client treatment needs and progress over time, what training, resources and supports might staff need? How might a clinician or caseworker’s workload impact client progress? Graph from: TCOM Report Suite — Minimum Standards for Vendors and Systems (Israel, 2015)

Attending to Progress: Provider or Program Level Maine EIS CANS Data System)

Attending to Progress Data source: TCOM Standard Reports 2. 0 (2016)

Attending to Progress: Questions for Supervision • How often/when is the CANS-NY administered during treatment? • Is the counselor identifying changes in CANS-NY item scores over time (up or down) by comparing sequential assessments and discussing the utility of the services provided in relation to specific CANS-NY scores (i. e. no change in school achievement over 12 months—is tutoring effective)? • What is the plan for sharing feedback about client change overtime as a method of discussing both areas of growth and continued need? • Have benchmarks been identified with the family that indicate whether progress is being made or not? • Does the provider celebrate progress with the family?

Attending to Progress: Program Level Data Source: Astor Services for Children & Families CANS-MH Data Set

Attending to Progress: Questions for Supervision • How often/when is the CANS-NY administered during treatment? • Is the provider identifying changes in CANS-NY item scores over time (up or down) by comparing sequential assessments and discussing the utility of the services provided in relation to specific CANS-NY scores (i. e. no change in living skills over 12 months—is training/coaching effective)? • What is the plan for sharing feedback about client change overtime as a method of discussing both areas of growth and continued need? • Have benchmarks been identified with the client/family that indicate whether progress is being made or not? • Does the counselor celebrate progress with the client/family?

SUPERVISION C-A-T-AP-ULT Treatment Planning Context Attending to Progress Assessment 45 Adapted from San Francisco County’s Family Driven Supports: Families Teach Best Practices in Assessment

Supervisee’s CANS Developmental Level: Training Strategies: New to the CANS Trained in TCOM and certified, becoming confident with CANS-NY content Full-day TCOM and CANS Review key aspects of -NY training; case at a CANS-item level in supervision; Enhanced content on canstraining. com; If possible, schedule and tape multi-session, full Mini-vignette domain collaborative CANS review. administration with a family/youth; Confident with basic CANS completion and administration; needs treatment planning supervision List 2/3 needs, 2/3 strengths; Cluster related needs. Identify key strengths to address clustered needs; Match clustered need/strengths to available treatments or Review current treatment referrals; plan in light of CANS. Identify gaps in plan and Use treatment-planning address. tool; Why wheel; Customize strategies for special populations (e. g. , complex trauma). Confident use of CANS with clients and for treatment planning Schedule a team CANS review on a contentious case. Advanced CANS-NY User Match supervisee’s selfidentified learning needs around treatment with CANS outcomes, reconcile discrepancies.

Supervisee’s CANS Developmental Level: New to the CANS Website Certification; Practice Strategies: Trained in TCOM and certified, becoming confident with CANS-NY content Confident with basic CANS completion and administration; needs treatment planning supervision Co-administer CANS with Use list, cluster, and seasoned user; strengths strategies with Observe seasoned CANS youth and family; user administer CANS; Contrast traditional case presentation with Implement customized Administer full CANS from completed CANS; identify strategy (e. g. , complex record review. gaps and reconcile; trauma checklist). . Role-play introduction of CANS/TCOM framework Develop game plan for to youth/family. domains/items to review CANS case conference: with family; Combine traditional case presentation with CANS Present action-item language to family; review item completion and key, salient CANS analysis. domains with family. Confident use of CANS with clients and for treatment planning Role-play/strategize for disagreement with youth/family on items; Advanced CANS-NY User Review CANS aggregate data with supervisee; Match supervisee’s Have those conversations assessment of systems with youth/family; reflect; gaps with aggregate data. Reconcile discrepancies. Develop a plan/role-play addressing no or low progress with youth/family; implement and reflect.

Pulling it all Together from an Information Science Approach: Communicate Using the CANS-NY Care: Planning Action Levels Timely Supervision: • Use the CANS-NY as a meaning making tool • Use the CANS-NY as a message of expectations • Use data to focus and inform the discussion at all levels of care and supervision The “What” Culture & Development • Incorporate consumer input, provider and managerial experience

Become a Champion (that’s what a Supervisor is meant to be!) • Let people in your organization know you are enthusiastic about TCOM and the CANS-NY! • Join the international learning community. (More about that later. ) • Express and show willingness to support others as they begin to use the CANS-NY – coaching, brown bag lunches, case conferences, etc. • Make sure others know about training opportunities in TCOM and CANS-NY.

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Thank you for your time and attention! Suzanne Button, Ph. D sbutton@chapinhall. org Chapin Hall at the University of Chicago 1313 E. 60 th Street Chicago, IL 60637