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Provider Focus Group survey results
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| Nebraska SIG Provider Focus Group Survey Results Kate Speck, PhD Executive Summary The purpose of this project was to gather information from the Nebraska provider network regarding four major areas: Barriers experienced in implementation of Evidence Based Practices, Knowledge of the Telehealth system and opinion on its use as a training venue, Training and Education that would enhance clinical skills; and currently used screening instruments for children and their families for depression, substance use, maternal depression. Focus Group Meeting Data:
Evidence Based Practices: It is clear that the respondents have a wide range of understandings of Evidence Based Practices (EBP). This ranges from not understanding which practices show empirical evidence to knowing a full range of EBP’s and utilizing them appropriately with the population with whom they are meant. Barriers identified to adopting EBP’s are focused in two general areas: 1) full and continuous funding, and 2) technical assistance to support therapists to have fidelity to the model that is selected. Funding is a primary issue – in that providers are willing to implement the protocols, however after training and implementation, often a new direction is chosen for the state system, leaving those who have expended staff and other financial resources for implementation and continuation of the protocol in financial bind. Knowledge of the Telehealth System Providers noted that the system could be used more often, especially with additional training in the use of the system tools, and technical assistance for trainers. Providers also need training on how to use the telehealth system. Using the system to increase family connections with their children and their families would be a beneficial use for the system. Some providers are well versed in using web-based training, and others, especially in rural areas have more limited access to the technology. Providers suggest that additional outlets are necessary for using the telehealth system, such as the school system, as well as what is available in hospital systems since these outlets have become limited. Cost shifting to have access to increased funding may provide an opportunity for more use of the system. The three largest issues are: 1) Accessibility to the telehealth venues, 2) Probability of multiple site problems with technology, 3) Consistent funding of the system. Education & Training Providers are enthusiastic about training and education to improve their clinical skills. A need for training across disciplines - parents/teachers/foster parents/child care providers/community regarding children’s mental health and substance abuse issues was identified as was training and the need to provide incentives to support a stable foster care provider group to address high need kids especially post adoption issues. There is insufficient understanding regarding cost shifting that occurs when funding is not approved for services that are provided. HHSS personnel attend nationally recognized trainings that therapists/parents attend in order to be able to speak to the same issues with the same information. Consultation groups to enhance training and technical assistance similar to the Omaha Metro Community Advocacy Coalition. Service Providers requested that there be a better connection between service providers – HHSS – Magellan to address the problems of lack of cultural sensitivity to customs/norms of families, and the issue of numerous case managers involved in families lives. Using parents as trainers would increase the trust level for families and would provide trainees with a perspective from a family perspective. Partnering with the Educational Service Units/Hospitals/County Health Departments would give another venue for training. Ongoing training that builds on previous trainings to address evolving issues and to keep the workforce. Have trainings relate to various skill levels of therapists – beginning, intermediate and advanced. Have more opportunity for web-based and telehealth trainings. Two areas that are currently in process have emerged that have promise for expansion: Region I has a video on parenting which is in process, and Omaha has a successful Early Childhood Mental Health Seminar Series addressing early childhood treatment processes and working with parents and problem behaviors. Providers discussed that time and travel costs to attend training can be prohibitive – the EBP trainings are often out of state or out of the area. Assessment Instruments A good bit of frustration was due to the number of assessment tools that are required for different funding sources and that there are too many tools that cover the same material, and none that have trauma issues included. Providers discussed the need for adequate psychological assessment for children leading to a treatment plan that covers individual needs. Currently used (not all required): CAFAS Child and Adolescent Functional Assessment Scale, Sensory profile (kids), Substance Abuse Subtle Screening Inventory SASSI -adolescent and adult, ACKENBACK – self check lists parents/teachers; PADDI – Practical Adolescent Dual Diagnostic Interview MA & SA screen; Infant-toddler Social Emotional Assessment ITSEA (ages 1 - 3) ITSEA (0 – 42 months); Brief Infant Toddler Social Emotional Assessment (BITSEA), Denver II, Ages and Stages; Ohio Scales -Youth 0ver 16; Chaffee - independent living - Over 18; Casey Life Skills Assessment – Transitioning; Youth Level of Service Inventory (YLSI); Massachusetts Youth Screening Instrument Version 2 (MAYSI-2); AAPI – Adult and Adolescent Parenting Intervention; Parenting assessment; Diagnostic Procedure Scale; New York and Safety & Risk Assessment; Health and nutrition assessments; IQ testing; Maternal Depression Screening; BECK – depression; EPDS (Edenburgh Post Partum Depression Scale); Zung Depression Inventory; Traumatic Brain Injury screen; BASC Behavioral Assessment Skills for Children; Neuropsyche assessment; Mental Status Exam; Childhood Onset Bi-Polar Disorders (COBD) – El Randolph – Colorado; Psychosocial/ family assessment; Pre-treatment assessment; A TSA – criteria developed to assess children under 12 for sexual issues; ERASOR -13+ sexual behavior problems; Child Sexual Behavior Inventory – CSBI; ADHD behavioral assessment system for children ages 3 – 14; 3 different levels; STRONGS inventory – also gender specific; Devereaux Early Childhood Assessment (DECA); Auchenbach child behavior checklist -18 months – 5; South Oaks Gambling Scale/GA 20 Q’s; OHIO – developmental screening; Myers Briggs Type Indicator; Minnesota Multiphasic Personality Inventory-A; Sex offender risk assessment; BASC – Behavioral Assessment Screening for Children; Suicide/homicide risk assessment; Attachment inventory; MIIM – theraplay assessment; Safe Harbor assessment; Modified Holland; Tulane/Dan Hughes. Evidenced Based Practices (EBP’s) It is clear that the respondents have a wide range of understandings of Evidence Based Practices (EBP). This ranges from not understanding which practices show empirical evidence to knowing a full range of EBP’s and utilizing them appropriately with the population with whom they are meant. Defining the evidence based practices (Question 19) was a question that did not result in a true understanding of what makes an Evidence Based Practice – responses ranged from “no knowledge of EBP’s” to a few who have expert knowledge in what it takes to be an EBP. In response to understanding relevance (Question 20) of EBP’s to their work, it is clear that respondent’s attitudes are that EBP is a constructive element, however, there is also a concern voiced related to the funding that is necessary to implement and continue using the protocols which can be costly, especially in private practices and smaller and more rural areas. Conditions that are helpful in promoting the adoption of EBP’s (Question 21) in clinical settings appear to be financial support to implement and study the client outcomes which may be more difficult for private practices and rural providers, Behavioral Health Regions inclusion in grant proposals, training on which EBP’s are appropriate for which population, HHSS, Medicaid, and private payers support in the form of payments for performing the practices, collaboration between providers to enhance skills with a peer based model of teaching-learning-supervision, supervision of novice professionals, and better all around clinical supervision. It looks as if the barriers identified to adopting EBP’s (Question 22) are focused in two general areas: full and continuous funding, and technical assistance to support therapists to have fidelity to the model that is selected. Funding is a primary issue – in that providers are willing to implement the protocols, however after training and implementation, often a new direction is chosen for the state system, leaving those who have expended staff and other financial resources for implementation and continuation of the protocol “in a lurch” due to the rapid shifting of adoption to the next new practice. Providers shared their frustration with wanting to provide the best possible treatment intervention, yet often their recommendations are not paid attention to or given their full due. A common problem is fidelity to the model – due to lack of good clinical supervision that goes over the entire spectrum of implementation and continued protocol. Often the clinical supervisors are asked to supervise elements that only their staff has been trained on, creating an information “bubble” that the staff must inform supervisors and in essence train/inform supervisors. Resistance from administration comes in the form of the time it takes for training staff and for adhering to models. In general, providers are positive about the implementation of EBP’s and want more training in all areas of training and understanding empirically supported treatment interventions (Question 23) which include: research descriptions of EBP’s; procedural protocols to guide EBP implementation, information on the contextual appropriateness of EBP’s, training/coaching on EBP usage, and use of a web-accessible database of EBP’s. Providers indicated that they would appreciate opportunities to seek funding for implementation and continuation of programs such as MST programs that have lost funding. Providers were savvy that they may need to implement a portion of the EBP’s that are appropriate to specific populations, but are aware that it is also a delicate process which may alter the protocol making the implementation more difficult and possibly not adhering to the original model. Supports/incentives that would be helpful for the promotion and use of EBP’s (Question 25) is clearly continued funding. One incentive would be to draw the circle of providers (treatment, community therapists, foster care personnel, schools, etc.) to the table and fund providers to attend team meetings for clients to improve communication and develop individual treatment plans. Another incentive may be to support travel for clients in rural areas. Clearly to have EBP protocols, there must be a critical mass – enough of the respondents to have fidelity to the model – and again, this is a hurdle that inhibits rural providers in this area. In relation to Nebraska implementing a process for nominating local practices (Question 26) as showing promise or as EBP’s there is enthusiasm and agreement that this would be something to promote. Barriers continue to elicit frustration regarding services that are given, yet reimbursement is often denied or extremely difficult to obtain – leaving providers to absorb the costs. Additional barriers discussed were the shortage of appropriate levels of care placements, and that creativity of providers to implement solutions is often overlooked. Training for system wide providers is seen as a bonus so that all service providers, funders and legislators are speaking the same language. Comments regarding implementation of a process for documenting client progress in response to treatment (Question 27) were somewhat mixed. Some providers saw this as an additional requirement that could be another unfunded obligation with time schedules already tight, providers wanted more information on how this would be implemented and who would be responsible for documentation. Many comments discussed that it would be useful to have this information, and that having a database to refer to regarding providers who are showing success, would give them someone to refer to when thinking of implementing new protocols. Service Providers have described barriers to implementing Evidence Based Practices in the field in several areas: Payment for Services
Providers expressed that they would like to see a resolution of the restrictions and constraints of funding to pay appropriate rates for services when providing evidence and best practice services. There is recognition from providers that in order to implement EBP’s there needs to be an ongoing state commitment and leadership to initiate not only to the model design, but to ongoing funding of projects. Providers discussed the cost implications in implementation of EBP’s as well as issues of replication related to the critical mass necessary to gather data especially in the rural areas. Rural providers stated that adjustments may need to be made based on these rural constraints, and that partial implementation of EBP’s as well as funders being open to allow funding for emerging and promising practices would be a benefit. There is a need to bridge the gap between mental health and substance abuse issues related to understanding the Recovery model versus a management model, and it was noted that funding streams need to blended, so that treatment for co-occurring disorders would be funded. A good trauma assessment is needed to accurately assess and treat trauma symptoms. In addition, a good family assessment tool would help to comprehensively assess the individual needs of families. Providers discussed the lack of agreement on which EBP, Best, and Promising Practice to use causes confusion, and that there is reluctance to train staff in protocols that may change without notice and no longer receive payment. For instance, CBT is an EBP, however there is new research suggesting that without accessing the emotional domain it may not have the same positive outcomes. Other: Providers discussed issues with language barriers and inadequate funding to be able to have interpreters and Latino/Sudanese bilingual therapists would be a positive change. Two other issues that emerged from the data were comments that youth who are experiencing difficulties attend school sporadically therefore they receive less services, and that it is difficult to find placement for violent and assaultive youth. Telehealth Responses There is a great variability in practitioners understanding of the telehealth system. The three largest issues are:
Providers have utilized the telehealth system for conferences, and training meetings, and are pleased due to the time saved in driving time which increased efficiency in providing services in client appointments, meetings and extended care opportunities. Providers noted that the system could be used more often, especially with additional training in the use of the system tools, and technical assistance for trainers. Providers also need training on how to use the telehealth system. Using the system to increase family connections with their children and their families would be a beneficial use for the system. Some adaptation is needed as not everything works over distance formats. For instance, this is a difficult format when used with children, and it may inhibit spontaneity for participation for sensory elements such as those used with play therapy. Additionally, trust and rapport need to be initially established so that the relationship can be extended in these formats. Education & Training The respondents had suggestions and training needs coming from a variety of areas: Clinician Training Needs:
Service providers have identified that there is a need for training for both foster care and adoption systems in Nebraska to address the service needs of children post-adoption. There was concern expressed that there is insufficient training to legislature regarding cost shifting that occurs when funding is not approved for services that are provided. Providers would like to see HHSS personnel attend nationally recognized trainings that therapists/parents attend in order to be able to speak to the same issues with the same information. Providers have identified a need for training for parents who fail to recognize the seriousness of developmental delays and continued emotional needs of their children. A need for training across disciplines - parents/teachers/foster parents/child care providers/community regarding children’s mental health and substance abuse issues was identified as was training and the need to provide incentives to support a stable foster care provider group to address high need kids. Training programs need to make sure students have the right skills to be prepared for treating high needs children and their families as well as new therapy models and EBP’s. A need for more collaboration with schools re: developmental issues and at risk issues i.e. attachment disorders/parenting skills for everyone. Consultation groups to enhance training and technical assistance similar to the Omaha Metro Community Advocacy Coalition. Need consistent model for training to provide specialized care for specific populations such as juvenile justice as well as cross training for schools/parents/providers so that communication is enhanced. Additional Recommendations: Clinicians make application to in order to provide services, yet Magellan does not refer to the applications, putting a burden on clinicians to verify their credentials repeatedly. Clinician skill levels are perceived to be negated by payors leaving services not reimbursed – clinicians are asked to make recommendations that are not followed or seen as valid. Service Providers requested that there be a better connection between service providers – HHSS – Magellan to address the problems of lack of cultural sensitivity to customs/norms of families, and the issue of numerous case managers involved in families lives. Creation of a directory of statewide EBP services in a hierarchy format from most evidence – to least would give providers a way to contact colleagues for technical assistance, and integration with the education system would initiate a process so schools would have a process to work with students that has an evidence base as well. Using parents as trainers would increase the trust level for families and would provide trainees with a perspective from a family perspective. Partnering with the Educational Service Units/Hospitals/County Health Departments would give another venue for training and the format should be offered at varying/multiple times in order to accommodate the needs of the trainees. Ongoing training that builds on previous trainings to address evolving issues and to keep the workforce motivated to use the evidence based practices. Legislators need to be informed about the state of the system and the need to respond more rapidly in intense situations. Family group conferencing is seen as an effective method to address children’s needs in a comprehensive manner, yet payment is not approved for therapists to participate in these activities. There is a need to use resources effectively yet when providers step out in being creative funding doesn’t cover services and needs. Telehealth and the internet are modes of training that would be helpful, and having regular consultation groups to enhance application of training skills for practitioners needs to be an important consideration. Getting really good assessments from qualified professionals is difficult – need additional clinical training; Developmental Disabilities assessment has same problem. Training needs to be offered on various levels – basic/intermediate/advanced to engage a range of practitioners. Additional training on Family Centered Care is necessary, and families need to be involved in providing this training, as well as being trained. Two areas that are currently in process have emerged that have promise for expansion: Region I has a video on parenting which is in process, and Omaha has a successful Early Childhood Mental Health Seminar Series addressing early childhood treatment processes and working with parents and problem behaviors. Use of Assessment Instruments for Children, Adolescents and Their Families Nebraska practitioners are using a variety of instruments to assess children and their families. Some of the instruments have been chosen by the agency, or individual therapist as to which will provide the most complete information that is not duplicated. A common theme was that there are various funding requirements for assessment tools that do not necessarily gather all of the necessary information for specialty areas; therefore, in order to fulfill the ethical responsibility of doing a comprehensive assessment, providers add tools that will best fit with the needs of the child and family. The following is a list of the various instruments that providers have been using in their pracrices: CAFAS Child and Adolescent Functional Assessment Scale Sensory profile (kids) Substance Abuse Subtle Screening Inventory SASSI -adolescent and adult ACKENBACK – self check lists parents/teachers PADDI – Practical Adolescent Dual Diagnostic Interview MA & SA screen Infant-toddler Social Emotional Assessment ITSEA (ages 1 - 3) ITSEA (0 – 42 months) Brief Infant Toddler Social Emotional Assessment (BITSEA) Denver II Ages and Stages Ohio Scales Youth 0ver 16 yo Chaffee - independent living - Over 18 yo Casey Life Skills Assessment – Transitioning Juvenile Justice – Youth Level of Service Inventory – MAYSI Massachusetts Youth Screening Instrument Version 2 (MAYSI-2) – Juvenile Justice Parenting Assessments
Functioning Assessments New York and Safety & Risk Assessment Health and nutrition assessments IQ testing Maternal Depression Screening Zung Depression Inventory Traumatic Brain Injury screen BASC Behavioral Assessment Skills for Children - Schools using Substance Abuse Subtle Screening Inventory SASSI -adolescent and adults Adults/Children Neuropsyche assessment Mental Status Exam Childhood Onset Bi-Polar Disorders (COBD) – ElRandolph - Colorado Psychosocial/ family assessment Need clinical interpretation skills for adequate reconnections Pre-treatment assessment A TSA – criteria developed to assess children under 12 for sexual issues – asso of treatment for sexual abusers 13+ sexual behavior problems – ERASOR – James Waherly
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