California’s Annual FFT Symposium 2008 Sustainability April 3, 2008 FFT LLC, 2008

Strong FFT (or any EBT) implementation requires major shifts in Training and consultation Training and consultation Practice, both clinical and supervisory Practice, both clinical and supervisory Assessment, and documentation, for youth and family, and therapist and supervisor Assessment, and documentation, for youth and family, and therapist and supervisor A different type of accountability A different type of accountability Funding practice Funding practice And in many cases referral practice And in many cases referral practice In order to achieve different (read successful) outcomes….

FFT Core Implementation Components FFT training to create model adherenceFFT training to create model adherence To training and supervision protocols and manuals To training and supervision protocols and manuals Clinician group of 3-8; ‘teamness’ / mutual supportClinician group of 3-8; ‘teamness’ / mutual support Therapist selection, team cohesion Therapist selection, team cohesion Well managed caseloads/referral processWell managed caseloads/referral process Case carrying FFT trained supervisor who follows FFT supervision protocolsCase carrying FFT trained supervisor who follows FFT supervision protocols Use of FFT web-based assessment systemUse of FFT web-based assessment system Not overwhelming therapists or families with other agency/other assessment and documentation Not overwhelming therapists or families with other agency/other assessment and documentation Targeted Quality Assurance to avoid therapist/supervisor driftTargeted Quality Assurance to avoid therapist/supervisor drift Clinical adherence (with families) Clinical adherence (with families) System barriers System barriers Interim outcome data (i.e. client completion, low caseloads) Interim outcome data (i.e. client completion, low caseloads) Well defined target populationWell defined target population FFT based discharge criteriaFFT based discharge criteria

Transporting FFT into the Community National Training Protocol Training Goals: Model adherence (successful replication) Model adherence (successful replication) Clinical and supervisory competence (model fidelity) Clinical and supervisory competence (model fidelity) Increasing self-sufficiency of therapist Increasing self-sufficiency of therapist Lasting and self sustaining sites Lasting and self sustaining sites Positive outcomes with families Positive outcomes with families Step 1: Site readiness Request For Program/Site Application Request For Program/Site Application Review / Feedback …around target population, referral process, team make up, service delivery Review / Feedback …around target population, referral process, team make up, service delivery Site Start-Up Site Start-Up

Transporting FFT into the Community National Training Protocol Training Phase I: CLINICAL TRAINING Primary Goals: Focus on the Team 1.Initial Implementation/technical training 2.2 day on site / 2 day off site clinical training (6 months out) 3.Phone consultation (weekly w/ National Consultant) 4.Follow-up training ((National Consultant-3 visits/year) 5.Externship 6.Clinical Services System (FFT-CSS)

Transporting FFT into the Community National Training Protocol Phase 2: SITE SUPERVISOR TRAINING Primary goals: Focus on the Supervisor Primary goals: Focus on the Supervisor Site Supervisor Training (2 two day trainings)Site Supervisor Training (2 two day trainings) Supervisor phone consultationSupervisor phone consultation Continuing Education (group)Continuing Education (group) Supervisor develops into the quality assurance role… Supervisor develops into the quality assurance role… Quality assurance/improvement monitor for the siteQuality assurance/improvement monitor for the site Therapist adherence/competence focusTherapist adherence/competence focus Model focused clinical supervision-Supervisor is guided by FFT Clinical supervision modelModel focused clinical supervision-Supervisor is guided by FFT Clinical supervision model

Transporting FFT into the Community National Training Protocol Phase 3: PARTNERSHIP Primary goals: Focus on a Long Standing Site Primary goals: Focus on a Long Standing Site – Demonstrate Adherence/competence – Continuing clinical/supervisor education Consultation/Quality Assurance Standards Consultation/Quality Assurance Standards Maintain appropriate caseloads of 12 to 15 cases at any given timeMaintain appropriate caseloads of 12 to 15 cases at any given time 2 hours/week consultation2 hours/week consultation CSS use as primary case management toolCSS use as primary case management tool Attend all staffings/trainingsAttend all staffings/trainings Individual therapist maintain adherence and competencyIndividual therapist maintain adherence and competency

Creating ACE: Adherence, Competence, Effectiveness Through the FFT Lens Adherence to the Clinical Model is the degree to which the therapist is doing the FFT program (clinical model) “as prescribed” with client families Adherence to the Clinical Model is the degree to which the therapist is doing the FFT program (clinical model) “as prescribed” with client families Adherence to the Dissemination Protocol is the degree to which the therapist is doing the FFT program (assessment protocol, staffing participation, CSS).Adherence to the Dissemination Protocol is the degree to which the therapist is doing the FFT program (assessment protocol, staffing participation, CSS). Technical elements Technical elements Service delivery within protocol Service delivery within protocol Competence reflects the skill of the therapist in providing FFT to families. Competence reflects the skill of the therapist in providing FFT to families. Ability to be clinically responsive to individual families (translate the model to the individual family) while Ability to be clinically responsive to individual families (translate the model to the individual family) while Remaining model focused (goals and skills), consistently practicing the model, and Remaining model focused (goals and skills), consistently practicing the model, and Thinking complexly about clients and the FFT therapy process Thinking complexly about clients and the FFT therapy process Effectiveness refers to outcomes (immediate, intermediate, long term) which reflects the complex intersection of many factors: Family member characteristics, Therapist adherence, Therapist competence, Referral system characteristics and processes, Agency system characteristics and processes Effectiveness refers to outcomes (immediate, intermediate, long term) which reflects the complex intersection of many factors: Family member characteristics, Therapist adherence, Therapist competence, Referral system characteristics and processes, Agency system characteristics and processes

FFT Organizational Components Model selection fits with the agency mission; support for doing evidence-based/family-based interventionsModel selection fits with the agency mission; support for doing evidence-based/family-based interventions Therapist/supervisor selection and support: willingness to learn, ability to apply protocolsTherapist/supervisor selection and support: willingness to learn, ability to apply protocols Broad Organizational Commitment toBroad Organizational Commitment to training and FFT site standards training and FFT site standards FFT assessment-web system FFT assessment-web system QA – QI protocols QA – QI protocols Commitment of resources to support programCommitment of resources to support program Commitment to data-outcomesCommitment to data-outcomes Strong relationships with referral agents/fundersStrong relationships with referral agents/funders

FFT External Influence Factors Support for evaluated programs -- evidence based and outcome focused practiceSupport for evaluated programs -- evidence based and outcome focused practice Support for adequate referral numbersSupport for adequate referral numbers Systemic support for fidelity: training & QA (funders, referral agents…)Systemic support for fidelity: training & QA (funders, referral agents…) Sustainable funding strategies (for services and QI)Sustainable funding strategies (for services and QI) Support for FFT congruent assessment / documentationSupport for FFT congruent assessment / documentation Ongoing support for outcomesOngoing support for outcomes Local ownership and choice (vs. top down)Local ownership and choice (vs. top down)

How not to sustain Lessons Implementation and agency selection based NOT on readiness but rather conscription or political pressure Implementation and agency selection based NOT on readiness but rather conscription or political pressure Provide funding that doesn’t fund all aspects of the clinical model; enforce productivity standards that not model congruent Provide funding that doesn’t fund all aspects of the clinical model; enforce productivity standards that not model congruent Use part time therapists whose non FFT activities overwhelm their focus Use part time therapists whose non FFT activities overwhelm their focus Conscript therapists who have only worked with individuals in office settings where showing up for appointments = readiness to change and where therapy is completed when clients stop showing up Conscript therapists who have only worked with individuals in office settings where showing up for appointments = readiness to change and where therapy is completed when clients stop showing up Use non model congruent assessment, have multiple assessment practices—one for funding, one for FFT, one from the agency Use non model congruent assessment, have multiple assessment practices—one for funding, one for FFT, one from the agency Use multiple agency teams where agencies are competitive and have no experience working together Use multiple agency teams where agencies are competitive and have no experience working together Be impatient. Don’t create a learning or QI environment but one of fear Be impatient. Don’t create a learning or QI environment but one of fear Don’t allow therapists, agencies, etc. to own the practice by micromanaging them Don’t allow therapists, agencies, etc. to own the practice by micromanaging them Assume referrals and referral practice will just fall into place Assume referrals and referral practice will just fall into place

The spark, chemistry Sometimes it’s a charismatic champion… Sometimes it’s a charismatic champion… Sometimes it’s only one person–therapists, administrator, funder. Sometimes it’s only one person–therapists, administrator, funder. Very well prepared, bright, know that they don’t knowVery well prepared, bright, know that they don’t know Own the practice, distribute successOwn the practice, distribute success Inspire, dogged, work harder but never say soInspire, dogged, work harder but never say so Passion. Simply own the territoryPassion. Simply own the territory When it’s more than one person, watch out When it’s more than one person, watch out Can be a well blended team—mutually supportive and accountable Can be a well blended team—mutually supportive and accountable

What’s keeps the spark going? For therapists, supervisors, and sites “When the relentless work to engage a family pays off and the show up for sessions” “When the relentless work to engage a family pays off and the show up for sessions” “Seeing the family members experiences change” “Seeing the family members experiences change” “When we are effective and families benefit” “When we are effective and families benefit” “Having a supervisor that supports the work we do” “Having a supervisor that supports the work we do” “Having a model that gives therapeutic work an anchor and focus for working with families” “Having a model that gives therapeutic work an anchor and focus for working with families” “Remaining non judgemental and blaming..respectfulness of the families and each other” “Remaining non judgemental and blaming..respectfulness of the families and each other” “A strong team” “A strong team” “Being given the resources needed to ensure quality FFT services” “Being given the resources needed to ensure quality FFT services”