BERRI: Outcome measurement, assessment and tracking tools for children with complex needs

Introducing BERRI Developed by, Dr Miriam Silver, a Consultant Clinical Psychologist and national expert in Looked After Children, BERRI is a set of outcome measurement tools that allow placement providers and commissioners to understand the needs of complex children, identify targets to work on and track how they change over time.

This can help inform placement choices, identify needs for therapy or specialist services, see whether interventions are effective, and track progress over time.

BERRI is the only assessment tool to cover mental health, emotional wellbeing, behaviour, risk and attachments.

Why measure outcomes? �  This is a highly complex population of children and young

people who deserve the best possible care

�  Such care is expensive and paid for from the public purse.

�  Looked After children go on to worse outcomes than their peers, which are also expensive to the public purse

�  Commissioners (and Ofsted inspectors) need to know that the placement is actively addressing the children’s complex needs, and is of the highest possible quality

�  Quality care is a worthwhile investment as it improves the life chances and long-term outcomes for children – something that also saves money in the long-term

Why use BERRI?

�  Placements using BERRI can evidence an average 14% improvement in score for children’s needs over six months of using the pathway

�  High level of satisfaction from service managers, care staff, social workers, commissioners, Ofsted inspectors

�  This care pathway and the BERRI “set a new gold standard for our members” – Jonathan Stanley, chair of ICHA

�  The BERRI is “the missing link in the residential care sector” - Sir Martin Narey, government advisor who reviewed residential care in the UK

Challenges for LAC �  Complex mixture of adversity, trauma, attachment,

mental health, neurodevelopmental, educational and social needs in Looked After Children

�  High level of mental health need

�  Limited CAMHS resources (perceived as inaccessible)

�  Variety of placement types, with little clinical governance

�  Multi-agency context, often out of area

�  Carers doing most of day to day work are often unqualified, disconnected from evidence-based interventions

Ofsted OFSTED: ‘It has been a cause of frustration that the inspection of children’s homes has been built on national minimum standards that do not have sufficient aspiration for these children and young people and regulations that are concerned mainly with process and procedure.

I am pleased, therefore, that the government has now introduced new regulations so that, from April 2015, our inspections will be able to focus more on outcomes for children and the quality of care they receive.

We want to see leaders, managers and staff teams who know the difference they are making to children and young people’s lives.

(Ofsted, Social Care, March 2015)

In Ofsted’s Inspection Framework they state that they will expect:

�  ‘children and young people to continually make progress from their starting points across all aspects of their development….

�  Managers have a clear understanding of the progress children and young people are making in respect of the plan for them.’

That is, there is a strong emphasis on having a clear plan, and a system of outcome measurement to show the progress you are making against this plan, in order to get good/outstanding Ofsted inspection results.

This is also a way to know you are doing good work, and regular use of outcome measurements has been shown to improve outcomes!

Ofsted

•  We need to assess the children we care for methodically

•  Gather information about their story •  Individualise their care based on this information •  Have high quality care plan documents •  Use evidence to decide who needs therapy, what

form and who will provide this •  Monitor how children are progressing •  Address issues with behaviour, mental health and

attachment •  Improve outcomes (with measurements to

demonstrate this)

What needs to change?

BERRI •  Developed through focus groups with those involved in foster

care and residential care

•  Covers a range of different types of concerns that relate to Looked After Children (not just behaviour or mental health)

�  Written in layman’s terms, not technical jargon, therefore accessible to carers

�  Themes �  Behaviour �  Emotional well-being �  Risk �  Relationships �  Indicators of potential need for assessment/diagnosis

�  Automated online scoring and reporting system

�  Ability to track change over time, and zoom in on specific issues

BERRI: paper version

Life events (to put scores in context)

Frequency and difficulty are both rated, as both contribute to the overall challenge

Items ask about a wide range of issues shown by LAC, in lay terminology

The BERRI system produces a number of different outputs to make the data immediately useful: •  Automated report, giving scores along with basic

advice about each of the 5 domains of need •  Spider plot illustrating the child’s score on the 5

domains •  Overlay on the chart to show change since last

assessment •  Ability to identify specific goals to address, and

track them in more detail over time •  Graphs to visualise change in target behaviours

over time, and allow identification of patterns

Outputs

BERRI: Spider plot

BERRI: Tracking

BERRI: Tracking

Why was there this peak in physical aggression? Does it recur on days with contact? Or when primary carer is not present? Or when there has been a difficult day at school? And what helped here?

The new strategies the psychologist advised seem to be effective in helping this child attend school

The BERRI system can help to keep an overview of all children who are the responsibility of a particular organisation like a Local Authority or placement provider. •  It can generate summary information about the

needs of the population (including the potential for custom reports eg how many children self-harm, demonstrate physical aggression, or are at risk of CSE?)

•  Information about change over time, taking account of life events (including “traffic light tables” of who is making progress and who needs additional input due to unexplained deterioration)

Organisation level data

Organisation level data

Graph of how children are progressing in one home (change in total BERRI score over 12 months) – new function coming soon

The BERRI system can help to make decisions about which type of placement to use, as we are collecting data about the scores that can be managed within adoptive families, foster placements, residential homes, secure units and other types of placements.

For example, some young people may have profiles that suggest they need residential care, and will no longer need to go via multiple foster placement breakdowns to get it. Likewise some young people in residential care may have settled to the extent that stepping down to foster placements is possible.

BERRI data will soon give us evidence about which placement pathways work and which don’t.

Organisation level data

BERRI provides a means to quantify the “value added” by various services or placement providers. •  We will soon have norms for the amount of

change that typically occurs in the BERRI profile for children of each age group, placement type or level of complexity.

•  We can then see whether particular interventions or placements improve these scores.

•  This will allow providers to evidence the efficacy of their services, and commissioners to make informed choices about which placements and services to commission.

Organisation level data

We recommend using the full BERRI at least four times per year, as this allows large changes to be identified and provides useful organisational data. The tracking system can be used daily or weekly to “zoom in” on the changes within particular areas of concern, or to see whether interventions are effective. We are currently working in collaboration with UCL and the University of Leicester to validate and norm the BERRI as a psychometric tool, and we regularly improve the features available to subscribers.

The wider picture

We see BERRI as one component of improving the quality of placements. As a stand alone tool it can help inform those caring for a particular child, and give useful data to service managers, commissioners and inspectors. However, it can also enhance the efficacy of existing interventions, or be one component in an evidence based, psychologically-informed care pathway. One example of how we have used BERRI is alongside staff training and regular consultations with a psychologist. We call this model PRIME.

The wider picture

PRIME Quality Standards

•  Psychological assessment •  Regular outcome measurement •  Individualised care-planning targets • Multi-faceted formulations •  Evidence-based interventions

Where these five factors are in place the network can work together to provide effective individualised care

How to implement a psychology pathway in practice

PsychologicalAssessment

(incIQ,mentalhealth,lifeskills)

Knowledgeoftheyoungperson’shistoryandcurrentpresentation(incstaffobservations,informationfromfile)

Multiagencymeetingtoshareformulationabouttheyoungperson,identifytargetsanddevelopstrategiesforintervention

Holisticoutcomemeasurement(usingBERRIchecklist)

Trackprogressusinggoal-based

outcomemeasurement

tool(usingBERRItargettracking)

Consultationwithstaffteamand

directtherapeuticinterventionsif

required

ModifystrategiesasrequiredAssessimpacton

overallqualityofcareinservice*

Weekly,fortnightlyormonthly,dependingoncomplexity

Quarterly

UpdateTherapeuticCarePlan

Stafftraining(tohelpthemunderstandattachment,neuropsychological

developmentandtheimpactoftrauma)

Once

BaselineStaffSurvey*

*Optionalresearchcomponents

Feedback “It is unusual to see an organisation be so clear and able to identify the issues for a child and to be able to be proactive about them. Its the swiftness at which you've identified the issues. CAMHS haven't been so quick or responsive and have never been so clear about the needs and how to work. Your pathway and use of the BERRI gives me confidence that you are meeting the needs and helping improve her outcomes and life chances. This level of insight is extraordinary, we don't even get it from the court process now. It feels like you are years ahead with your process. You set the standard for the network. You start at the beginning and not the end, identifying the needs and strategies to work on them not just vaguely trying to meet the Every Child Matters five outcomes. In short, I'm impressed."

�  Social Worker from Sunderland in relation to a home that had our full psychology pathway.

Quality Mark for providers

We would like to form a consortium and award this mark to providers meeting the standards we have set out

Use resources differently

We think a little bit of psychology can go a long way:

•  Training carers and professional networks around the child to understand attachment, the impact of trauma, basic neuroscience and effective strategies for reparative care

•  Working with organisations to bring in clinical governance and effective universal care pathways for Looked After Children in their placements

•  Provide evidence-based psychological therapies

•  Liaison with other agencies to ensure access to appropriate services for specialist needs and providingp sychology input to panels

For more information:

�  Email: Lifepsychol@gmail.com

�  Office phone: 07525 869980