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Practice & System Development using QSR

Developing World Class Practice!

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Questions to ConsiderWe do good with many consumers

and families but not all consumers and families.

Who do we succeed with and who do we fail?

What can we do differently to help more consumers, children and families more of the time?

What can we change on our part to increase each consumer and child’s chance of success?

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Why did you go into this work?

I wanted to get rich?

I wanted to help people and make a difference?

How does it feel when You succeed?

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Energizing Practice DevelopmentInspire, Teach, Learn

Tap into peoples passion that brought them to this work!Make the expectations for world class practice crystal clear throughout all Behavioral health community! Focus on successful practices and results.Problem solves barriers based on concrete examples in small steps.

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Practice that Works Strong consumer and family

engagement, Excellent communication of team

members,Good understanding of consumer’s

needs, strengths and context, Clear goals and outcomes,Wise choice of intervention

strategies, Evidence Based treatments,

Engage consumer’s strengths,

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Practice that WorksSense of Urgency and TimelinessWe do what it takes to get results,We change what we are doing if

we are not making progress,Our bosses/supervisor make

practice top priority and support us to do what we need to do.

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8COORDINATINGInterventions, Data,Decisions, Resources

Core Functions in Practice

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ENGAGING child/ Family Members/

Assemble Family Team/

ASSESSING & UNDERSTANDING Current Situation, Strengths, Needs,

Preferences, Context

TEAM PLANNING: OUTCOMES &

STRATEGIES for achieving the outcomes

RESOURCING Planned Intervention Strategies, Actions, and Supports

IMPLEMENTATION: Using Intervention

Strategies, Supports, and Transitions

TRACKING Progress, Results, What’s Working;

Awareness of changing context.

ADAPTING Services Through On-going

Assessment and Planning

Key Functions in a Basic Practice Model

ELIGIBLE CHILD & FAMILY => ENTRY

OUTCOMES & REQMTS MET =>

STEP-DOWN or EXIT

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What is QSR?

• The Quality Service Review (QSR) is a way of knowing what’s working at the point of practice delivery for specific consumers and why.

• QSR connects practice to results and results to frontline working conditions in local sites.

• QSR is a teaching process that clarifies expectations, provides feedback, and stimulates thinking and next step actions to improve practice and results.

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The Quality Service Review

Uses a CASE REVIEW that measures performance at the PRACTICE POINTS.

Shows WHAT’S WORKING and NOT WORKING for different consumers & families.

Uses focus group interviews & key indicators to put practice into context.

Drives PRACTICE DEVELOPMENT & capacity building to get better results.

Client Status,Case Practice,

Present Results

A Lens for Viewing OurPractice & Results

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Key Concepts

Each consumer, child and family served can be viewed as a unique and valid “TEST” of daily front-line practice.

Services should RESPOND appropriately to each consumer and ADAPT as circumstances change.

Services should improve a consumers FUNCTIONING and WELL-BEING while reducing RISKS of harm..

Service systems must have the capacity to LEARN and CHANGE to improve practices and results.

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How Does QSR Bring Change?

• Applies the practice model to actual cases to measure adequacy based on progress and results.

• Finds and affirms good practice in real cases.• Provides immediate feedback to frontline practitioners.• Uses grand-rounds to teach from consumers and children

reviewed about what’s working now and what to do next.• Stimulates local supervisors and managers to take next steps

and enables effective use of technical assistance.• Identifies local and state level system barriers.

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QSR Shifts the Focus

Policies & procedures Documentation Organizational structure Program requirements Funding & expenditures Compliance & control

Guiding principles Practice model in use Daily case-level practice Frontline conditions Adeq./flex. of resources Results & outcomes

Compliance Practice & Results

Get & Keep $$$ Get Good Results

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What did we do!Since inception of QSR Protocol design and pilot, we have:conducted 2 Reviewer trainings on the children’s QSR protocol and 2 trainings in the adult QSR protocol;

31 local agency staff and 19 state staff participated in training;

provided “on-the-job” review opportunities to 50 trained persons who were “shadow reviewers” in local QSR onsite reviews ;

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What did we do!conducted onsite reviews in 9 communities across 18 agencies (9 children and 9 adult agencies).

Reviewed specific practices with 35 children and families

Reviewed specific practices with 23 adult consumers

Interviewed more than 600 persons involved with behavioral health services in the 9 communities.

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What were we trying to accomplish?Direct more focused attention on the core mission of high quality and consistent practice,

Stimulate more focus and discussion on the core practice functions of engagement, deep understanding, teaming, communication and collaboration, and timely and consistent implementation,

Obtain an initial impression of how consistently these functions were occurring internal to CSAs and across agencies

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What were we trying to accomplish?Introduce CSA/agencies to the qualitative consumer review process of QSR used as a practice development tool,

Introduce a common framework for examining, discussing and refining practice,

Gather some initial information about the quality and consistency of practice in the new CSAs,

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What were we trying to accomplish?Observe and learn about the progress communities were making to develop collaborative approaches to maximizing resource across all stakeholders involved with serving children and adult MH consumers.

Develop capacity in New Mexico to conduct and use QSR for practice development.

Determine what the best path for further expansion of the use of QSR might be

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What we Learned OverallThere are many strengths in the services across the state.

CSAs are being implemented but are very early in development therefore their role and mission are not fully understood by all stakeholders.

Consumers are getting services, sometime after delays, and the quality of teaming, communication and implementation can range from excellent to fragmented.

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What we Learned OverallThere is communication across agencies but few examples of integrated well-coordinated program/community efforts.

The quality and consistency of the implementation of recovery model and the SOC/Wrap model of practice is fairly variable with the biggest challenges being interagency teaming and communication and access to the necessary services.

For QSR to be used effectively in the future as a practice development tool, the process of implementation needs to be refined, probably largely internalized by CSAs and supported with appropriate resources.

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What we Learned!Strengths

Strong commitment to good practice expressed by leadership.

Strong commitment to to making adjustments and problem solving to get the best results.

Caring and dedicated staff committed to making a difference for their clients

Internship programs and supports for licensure to recruit and retain staff

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What we Learned!Strengths

Communities were very positive about evidence based programs such as MST and Treatment Foster Care.

High need kids are being sustained in the community with intensive family centered services.

Kids are stepping down from higher levels of care in a responsive and timely manner

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What we Learned!Strengths

Examples of well trained behavior management specialists helping children, parents and teachers to provide appropriate contingency management with documented positive results.

A number of examples of programs in communities that were very well thought of such as Cross Roads, Clarity House, Round tree 0-3 program, juvenile assessment center, shelter group homes, school program in RTC, mobile crises outreach, ACT team, drug court

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Themes and ChallengesRecruitment and Retention in some areas is challenging requiring support and resources

Difficulties accessing and maintaining housing; decrease in housing and homeless resources,

Insufficient number of treatment Foster Care Homes combined with lack of skills necessary to effectively serve the most in need children

Consumers lacking meaningful daily activities

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Themes and ChallengesReasonable working relationships were observed across agencies but little truly collaborative cross agency planning and program development was reported or observed.

Frustration with long waiting lists, difficulties in getting youth into more intensive programs and having to send youth long distances for services.

Creating holistic ownership across child serving agencies of improving the well-being of children.

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Themes and ChallengesAll providers report serving higher acuity levels in shelter/group homes, TFC and other programs.

Too short periods of authorization when longer time is obviously needed.

Great need for more bilingual/cultural therapeutic capacity.

Refining communication and teaming across agencies to insure that no child and family fall through the cracks in communication and teaming.

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Challenges To CSAsClarity of vision, objectives and goals communicated to community partners.

Developing and clarifying the role and functions of CCSS services

Clarifying how CSA will work with all community partners to help provide/find needed services for eligible children and adults in other settings, i.e. schools, detention, jails,

Clarify how services will be coordinated at the child level across agencies.

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State level ChallengesFining tuning the business/funding model to fully support the family centered, team based, recovery practice model. Authorization and billing parameters not supportive of good teaming.

Need to provide clear expectations/guidance in all child serving agencies of the mandate to participate in interagency teaming and effective reciprocal communication. Clear practice expectations!

Clarify the the rules for information sharing to facilitate services to consumers and families

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Working with Optum HealthCelebrate effective collaboration by local Optum Health care coordinators with some kids and teams.

Community perception that multiple failures and crises are required to get the appropriate services resulting in potentially irreparable harm to child or adult consumer.

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The Positive Workplace = Hope

• Expectations are clear and tools are provided• Workplace/employee fit - ability to use

strengths• Commitment to the mission and sense of

belonging• Opportunities to discuss progress and grow • In human services, “we do what it takes to

make a difference with our clients”.• “My supervisor makes me feel inspired and

motivated”

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Let’s Talk!

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