Connecticut TF-CBT Coordinating Center FY 2013 Annual Report Jason M. Lang, Ph.D. Carol O Connor, LCSW Michelle Delaney Robert P. Franks, Ph.D.

Connecticut TF-CBT Coordinating Center FY 2013 Annual Report Jason M. Lang, Ph.D. Carol O Connor, LCSW Michelle Delaney Robert P. Franks, Ph.D. Center for Effective Practice Child Health and Development Institute of Connecticut

Connecticut TF-CBT Coordinating Center FY 2013 Annual Report Jason M. Lang, Ph.D. Carol O Connor, LCSW Michelle Delaney Robert P. Franks, Ph.D. Center for Effective Practice Child Health and Development Institute Farmington, CT This report was developed for the Connecticut Department of Children and Families (DCF) as a publication of the Center for Effective Practice (CCEP), located within the Child Health and Development Institute of Connecticut (CHDI).

INTRODUCTION This report summarizes the work of The Connecticut TF-CBT Coordinating Center, funded by the Connecticut Department of Children and Families (DCF), for state fiscal year 2013 (July 1, 2012 through June 30, 2013). The Connecticut TF-CBT Coordinating Center is located at the Center for Effective Practice (CCEP), within the Child Health and Development Institute of Connecticut (CHDI). Since the initial implementation of TF-CBT in Connecticut through the use of Learning Collaboratives in 2007-2010, the TF-CBT Coordinating Center has provided ongoing support to Connecticut agencies trained in TF-CBT. This support includes (1) Training, (2) Data Systems Development, Collection & Reporting, (3) Consultation & Technical Assistance, (4) an Annual Conference, and (5) Coordination and Administration. BACKGROUND Trauma Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based, short-term, family-centered behavioral health treatment for children suffering from exposure to potentially traumatic events, including physical abuse, sexual abuse, domestic or community violence, accidents, or disasters. TF-CBT is indicated for children who are suffering from traumatic stress symptoms related to trauma exposure, including symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety. TF-CBT has been designated as an exemplary treatment on the National Registry of Evidence Based Programs and Practices (NREPP) by the Substance Abuse and Mental Health Services Administration (SAMHSA). From 2007-2010, DCF funded a statewide dissemination of TF-CBT across community behavioral health agencies in Connecticut. CHDI was selected as the Coordinating Center for this initiative, called the Connecticut TF-CBT Learning Collaborative. CHDI utilized the Institute for Healthcare Improvement s Breakthrough Series Collaborative quality improvement model, in consultation with national experts in the National Child Traumatic Stress Network (NCTSN), to train staff from 16 community behavioral health agencies in TF-CBT. 2

Upon completion of the learning collaboratives in 2010, DCF identified the need to provide statewide infrastructure to sustain TF-CBT across the behavioral health agencies trained in the learning collaboratives. In 2010, the TF-CBT Coordinating Center was established at CHDI to provide this support. In 2011, DCF was awarded a federal grant by the Administration on Children and Families to improve trauma-informed care for children in the child welfare system. This Coordinating Center for this initiative, called the Connecticut Collaborative on Effective Practices for Trauma (CONCEPT), is also located within CHDI, and the TF-CBT Coordinating Center has provided additional support to additional agencies trained in TF-CBT through CONCEPT 1. This report summarizes the work of the TF-CBT Coordinating Center for SFY2013. GOALS The primary goals for the TF-CBT Coordinating Center in SFY2013 were to (1) increase the number of children receiving TF-CBT (2) increase the number of clinicians trained to provide TF-CBT (3) improve the quality of TF-CBT treatment An additional goal added during the year with DCF was to facilitate TF-CBT provider collaboration with local DCF area office staff. As part of the CONCEPT grant, six new behavioral health agencies were trained in TF-CBT during SFY2013 through learning collaboratives that also included child welfare staff from DCF area offices. Through CONCEPT, DCF also sought to improve coordination between the network of TF-CBT providers and their local DCF area office staff. The TF-CBT Coordinating Center has worked to support these new TF- CBT providers and to facilitate collaborations between all TF-CBT providers and DCF staff in SFY2013. The six CONCEPT agencies provided 1,979 TF-CBT sessions to 197 children and families in SFY2013, in addition to those served by the 16 existing TF-CBT agencies. 3

ACTIVITIES The TF-CBT Coordinating Center worked to reach the identified goals through four primary activities: (1) Training, (2) Data Systems Development, Collection & Reporting, (3) Consultation & Technical Assistance, (4) an Annual Conference, and (5) Coordination/Administration. The TF-CBT Coordinating Center served the 16 TF-CBT agencies that completed Learning Collaboratives between 2007-2010, and began to support the six agencies that participated in the CONCEPT TF-CBT Learning Collaborative during SFY2013. Thus, support was provided to 22 community based agencies providing TF-CBT throughout the state (see map in Appendix 1) through the following activities: 1. Training Provided a two day clinical training with a national TF-CBT trainer to 86 new TF-CBT clinicians and 47 staff from the CONCEPT agencies. Held a series of 9 hour-long webinars facilitated by a Master TF-CBT trainer, attended by a total of 112 staff (some clinicians attended more than one call, and may be counted more than once) Held training for agency TF-CBT Coordinators, including training on new assessment measures, which was attended by 17 staff 2. Data Systems Development, Collection, and Reporting Developed, monitored, maintained, and provided technical assistance for an online data entry and scoring database of clinical assessments for each of the TF-CBT agencies Managed an online monthly metric survey completed by all clinicians who provide TF-CBT throughout the state (2,607 clinician Metrics completed) Developed monthly metric dashboard templates for data reporting Analyzed data, prepared, and distributed a monthly metric report and dashboard to all staff and DCF monthly Maintained a statewide TF-CBT intranet site with resources and a location to post questions on a private discussion board Maintained internal database of all staff trained at the TF-CBT agencies 4

Prepared monthly report for each of the 16 TF-CBT agencies detailing the status of assessment measures for each client. The same monthly report was also prepared for the 6 CONCEPT agencies Revised TF-CBT client assessment measures and metrics and updated databases Provided site-based data assistance and reports as requested 3. Consultation & Technical Assistance Developed statewide and site-based TF-CBT provider goals for each of three performance periods, typically focused on increasing capacity Monitored and distributed DCF funded Performance Incentives to agencies that met the established goals for each performance period Worked with each provider agency to develop site-based Performance Improvement Plans for each of the three performance periods (16 agencies X 3 plans = 48 Performance Improvement Plans) Worked with each provider agency to develop strategies for improving TF-CBT delivery Provided 48 in person site-based consultations with TF-CBT provider staff (16 agencies X 3 site visits) to improve performance Provided 32 site-based consultations with TF-CBT provider staff and local DCF staff, including office staff and trauma champions, to facilitate collaboration. Provided telephone and email site-based consultation with all agencies Updated the information needed and process for making TF-CBT referrals and admissions for each agency Identified staff contacts in each agency and DCF office to facilitate communication on TF-CBT cases Collected information from each agency about the trauma screening process and the use of standardized measures to assess trauma history and symptoms. Seven agencies use a standardized screening tool and the other agencies use their own selected screening questions. 4. Annual Conference Developed conference structure and focus, and identified outside speaker 5

Developed request for proposals, reviewed proposals, and encouraged participation by TF-CBT providers Convened the fifth annual TF-CBT conference, which was attended by 238 clinicians, supervisors, senior leaders, family partners, DCF staff, and others. In addition to a keynote speaker, Dr. Benjamin Saunders, 23 TF-CBT-related workshops were offered CEUs were provided for all staff who were eligible to receive them 5. Coordination/Administration Facilitated three Senior Leader Meetings with Senior Leader representatives of the TF-CBT agencies Managed a database of more than 400 active TF-CBT providers and developed a database to record attendance at clinician training activities Coordinated registration, attendance and CEUs for New Clinician Training (133 participants) and the Annual TF-CBT Conference (238 participants) Provided a monthly update to all TF-CBT Learning Collaborative participants through a newsletter, Metric Report and Dashboard Worked with DCF and CHDI staff to integrate TF-CBT network with CONCEPT initiative and the entire child welfare system Worked with DSS to begin developing guidelines for billing TF-CBT client sessions Facilitated and attended 32 Meetings with TF-CBT providers and local DCF staff to support collaboration Other Developed an Evidence Based Practice Cost Survey and worked with providers to gather data on the costs of providing TF-CBT treatment. This information is being analyzed and will be reported shortly. OUTCOMES The following data summarizes the outcomes for the sixteen TF-CBT agencies in FY13. Please see additional data in Appendices 3 (data from FY12), 4 (data from FY13), and 5 (data from the CONCEPT TF-CBT agencies). 6

766 clients received TF-CBT across the 16 provider agencies during FY13 (relatively unchanged from 776 in FY12) There were 361 clinicians who provided TF-CBT, including 85 newly trained clinicians (relatively unchanged from 363 in FY12, due to staff turnover) 257 children successfully completed TF-CBT successfully (relatively unchanged from FY12) Of closed TF-CBT cases, 55% were completed successfully (a significant increase from 46% in FY12) The participating agencies provided TF-CBT to an average of 4.3% of their enrolled clients (down slightly from 4.7% in FY12) Staff turnover, defined as the percent of staff who started the year on the TF- CBT team who left the team during the year, increased from 51% to 60% from FY12 to FY13. 14 of the 16 eligible agencies met at least one Performance Goal and received a Performance Incentive Four agencies met the statewide goal in two Performance Periods Three agencies met their agency specific goals in two Performance Periods 8,875 TF-CBT sessions were provided during FY13 (a decrease from 9,144 in FY12) As of May, 2013, 490 clinicians; 72 supervisors; 53 Senior Leaders; 22 Family Partners and 46 DCF staff had received TF-CBT training since 2007 CHALLENGES The following challenges to sustaining or expanding TF-CBT have been identified by agency administrators, clinicians, child welfare staff, and CHDI project staff: Additional time and cost of providing TF-CBT (e.g. lost productivity for meetings, additional coordinator responsibilities, data entry, staff training) Lack of ability/ time to train new staff internally (intensive training is only provided annually by a TF-CBT trainer) Average staff turnover rate of 60%, and especially turnover of Coordinators and Senior Leaders. This represented an increase of almost 10% over FY12. 7

Limited incentives for providers to expand TF-CBT are not nearly enough to balance the costs of providing evidence-based treatment No contract or policy requirements or incentives for providers to utilize evidence-based treatments Vicarious traumatization of staff impairs their ability to provide treatment Difficulty scheduling TF-CBT clients weekly (as prescribed by the model) given high caseload requirements and an inability to see every child on a caseload weekly Limited availability of supervision with a trained and experienced TF-CBT supervisor Staff training in the use of standardized assessments in clinical practice is limited Lack of a standardized, statewide TF-CBT credentialing process (note: National TF-CBT Certification was just announced, but requires $250 fee and is for licensed clinicians only) Staff difficulty initiating TF-CBT cases due to apprehension about their TF-CBT skill level and limited supervision/support to learn the model The increasing number of agencies and staff has resulted in additional needs for consultation, technical assistance, and data collection that stretches the Coordinating Center s current resources Existing data systems are no longer capable of collecting the volume of data that TF-CBT providers currently produce, given the increasing numbers of staff and agencies in recent years Current data system is unable to provide information to agencies in real time. Coordinating Center staff have limited resources to support child welfareprovider collaboration in addition to TF-CBT sustainability efforts Inconsistent participation of child welfare staff and provider staff, likely due to high demands on each, has been a barrier to improved child welfare/provider collaboration on TF-CBT cases and increasing referrals from DCF staff to TF-CBT providers Lack of TF-CBT availability in some rural areas, and in other settings (schoolbased, private practitioner, providers that accept commercial insurance) 8

RECOMMENDATIONS The following recommendations are made for continued support of the expanding TF-CBT statewide network: Provide incentives to providers of TF-CBT (and other evidence-based treatments) that meet performance benchmarks Support expansion of TF-CBT through policy and contracts that support, require, and/or incentivize use of evidence-based treatments Provide resources for a new data system to account for the increased volume of data provided by, and reported to, TF-CBT agencies, and to simplify data reporting for providers Provide additional opportunities for staff to receive TF-CBT training and ongoing clinical support Provide a pathway and opportunities for staff to receive state credentialing and National Certification in TF-CBT Provide training opportunities for clinical use of standardized assessments Develop a consistent, standardized trauma screening process and screening measure for all agencies that is included in PSDCRS Support child welfare staff s collaboration with TF-CBT providers for referrals and ongoing collaboration about children receiving treatment Provide education to child welfare staff about the value of evidence-based treatment and TF-CBT when making referrals for behavioral health services, how to assess the type of treatment a child is receiving, and how to advocate for evidence-based treatment Expand training opportunities for clinicians in rural and other underserved areas, clinical settings other than outpatient clinics, and in private practice and school-based settings 9

Appendix 1: TF-CBT Providers Map

Appendix 2: TF-CBT Providers List

Appendix 3: TF-CBT Provider Outcomes for SFY12 Fiscal Year 7/2011-6/2012 # # Clinicians TF-CBT team turnover # client # TF-CBT % TF-CBT # TF-CBT # cases # cases % cases TF-CBT Agency Clinicians trained rate episodes Cases cases sessions closed completed completed Bridges 13 3 50% 321 36 11% 340 24 16 66% Charlotte Hungerford 12 1 14% 888 99 11% 992 82 57 70% CFA (3 sites) 24 6 42% 923 74 8% 1029 47 31 66% CGC Southern CT. 26 4 72% 926 25 3% 531 26 14 54% CGC Central CT. 16 3 53% 700 46 7% 450 22 4 18% Clifford Beers 29 4 47% 1114 49 4% 520 28 10 36% Community Health Center 33 7 33% 714 21 3% 266 19 11 58% Community Health Resources 20 5 67% 1577 56 4% 456 40 8 20% FCA 25 6 48% 1211 17 1% 361 15 3 20% Cornell Scott- Hill Health Center 21 6 22% 1137 64 6% 897 58 14 24% UCFS 24 7 67% 1204 35 3% 436 34 13 38% The Village 42 7 39% 2403 77 3% 957 55 18 33% Wellmore 19 3 75% 1450 49 3% 571 35 15 43% Wheeler Clinic 23 2 59% 1428 64 4% 512 37 12 32% Klingberg 20 2 52% 251 28 11% 473 39 34 87% FSGW 16 5 72% 87 36 41% 353 23 11 48% Statewide 363 71 51% 16334 776 4.7% 9144 584 271 46%

Appendix 4: TF-CBT Provider Outcomes for SFY13 Fiscal Year 7/2012-6/2013 # # Clinicians TF-CBT team turnover # client # TF-CBT % TF-CBT # TF-CBT # cases # cases % cases TF-CBT Agency Clinicians trained rate* episodes cases cases sessions closed completed completed Bridges 11 2 60% 324 61 19% 552 33 17 52% Charlotte Hungerford 12 4 14% 705 90 13% 1066 77 55 71% CFA (3 sites) 24 8 45% 969 68 7% 1086 46 26 57% CGC Southern CT. 26 4 83% 861 26 3% 445 10 4 40% CGC Central CT. 16 4 71% 624 31 5% 318 20 6 30% Clifford Beers 29 4 77% 1221 36 3% 402 16 12 75% Community Health Center 33 10 42% 816 18 2% 167 14 10 71% Community Health Resources 20 1 63% 1889 58 3% 450 36 23 3% FCA 25 6 56% 1828 30 2% 442 14 8 57% Cornell Scott- Hill Health Center 21 5 29% 1133 52 4% 929 43 21 49% UCFS 24 7 79% 1292 22 2% 210 9 5 56% The Village 42 7 58% 2315 63 3% 572 16 9 56% Wellmore 19 7 83% 1450 60 4% 606 49 18 37% Wheeler Clinic 23 5 75% 1643 106 6% 1086 44 24 55% Klingberg 20 5 63% 319 17 5% 273 22 11 50% FSGW 16 6 67% 112 28 25% 271 19 8 42% Statewide SFY13 361 85 60% 17501 766 4.4% 8875 468 257 55% Statewide SFY12 363 71 51% 16334 776 4.7% 9144 584 271 46% * The percent of all TF-CBT clinicians who were on the team at the start of the year who were no longer on the team at the end of the year.

Appendix 5: CONCEPT Provider Outcomes for SFY13 Fiscal Year 7/2012-6/2013 # clinicians # client # TF-CBT % TF-CBT # TF-CBT # cases # cases CONCEPT Agency # clinicians trained episodes cases cases sessions closed completed* CFG Center- Bridgeport 10 9 1302 82 6% 664 31 1 CGC of Mid Fairfield 9 7 335 25 7% 239 5 0 Community CGC, Manchester 12 7 810 29 4% 283 6 0 CMHA (2 locations) 17 10 934 11 1% 100 6 0 LNVPCRC 7 6 330 26 8% 452 13 1 United Services 10 9 1090 24 2% 241 5 0 Statewide 65 48 4801 197 4.1% 1979 66 2 * The length of TF-CBT treatment and timing of the learning collaborative implementation year is such that few cases are completed before the end of the learning collaborative. However, cases typically begin to close soon after the learning collaborative ends.