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Researching Wraparound in Nevada Overview of the Youth and Family
Researching Wraparound in Nevada Overview of the Youth and Family
Overview of this Presentation
Overview of this Presentation
What is an Evidence Based Practice
What is an Evidence Based Practice
We have treatments with evidence for effectiveness for
We have treatments with evidence for effectiveness for
Unfortunately, major barriers to using EBPs in real world practice
Unfortunately, major barriers to using EBPs in real world practice
Theory of change: Why wraparound may be critical to positive outcomes
Theory of change: Why wraparound may be critical to positive outcomes
Promising Outcomes for Communities using the Wraparound Process
Promising Outcomes for Communities using the Wraparound Process
Outcomes  Wraparound Milwaukee
Outcomes Wraparound Milwaukee
Results from Nevada: Living in less restrictive, more community based
Results from Nevada: Living in less restrictive, more community based
Results from Nevada: Functioning better in the community
Results from Nevada: Functioning better in the community
Results from Oklahoma: Getting to permanency
Results from Oklahoma: Getting to permanency
Results from Oklahoma Supporting re-integration of adult prisoners
Results from Oklahoma Supporting re-integration of adult prisoners
OK, so the theory of change makes good sense
OK, so the theory of change makes good sense
A National Review of Wraparound Teams Showed (Walker, Koroloff, &
A National Review of Wraparound Teams Showed (Walker, Koroloff, &
Hospitable
Hospitable
System and organizational supports for wraparound
System and organizational supports for wraparound
System and organizational supports for wraparound
System and organizational supports for wraparound
Monitoring quality of implementation of child and family teams
Monitoring quality of implementation of child and family teams
Wraparound Fidelity Assessment System
Wraparound Fidelity Assessment System
Summary: What Leads To Outcomes
Summary: What Leads To Outcomes
A summary of research on wraparound implementation
A summary of research on wraparound implementation
Studying Wraparound Implementation in Nevada
Studying Wraparound Implementation in Nevada
The Outcomes of Wraparound in Nevada Study
The Outcomes of Wraparound in Nevada Study
Major Research Questions
Major Research Questions
Study population
Study population
What data is the Youth and Family Supports Study providing
What data is the Youth and Family Supports Study providing
Additional data from the Youth and Family Supports Study
Additional data from the Youth and Family Supports Study
Progress report
Progress report
Study Enrollment to date
Study Enrollment to date
Characteristics of YFSS Participants
Characteristics of YFSS Participants
Demographics
Demographics
Referral and study information
Referral and study information
Placement and Placement History
Placement and Placement History
DSM Diagnoses assigned (N=30)
DSM Diagnoses assigned (N=30)
Number of Diagnoses Assigned (N=30)
Number of Diagnoses Assigned (N=30)
CAFAS Functioning Subscales: Percent of youth with moderate to
CAFAS Functioning Subscales: Percent of youth with moderate to
Findings on Wraparound Implementation in Nevada from the YFSS
Findings on Wraparound Implementation in Nevada from the YFSS
Baseline Fidelity data assessment (2006-07)
Baseline Fidelity data assessment (2006-07)
Baseline Fidelity data assessment (2006-07)
Baseline Fidelity data assessment (2006-07)
Results of Fidelity Assessment: Strengths of wraparound implementation
Results of Fidelity Assessment: Strengths of wraparound implementation
Results of Fidelity Assessment: Needs for improvement
Results of Fidelity Assessment: Needs for improvement
Summary scores: Wraparound Fidelity Index Compared to another state +
Summary scores: Wraparound Fidelity Index Compared to another state +
More Results on Wrap Implementation: From the Community Supports for
More Results on Wrap Implementation: From the Community Supports for
The Community Supports for Wraparound Inventory
The Community Supports for Wraparound Inventory
Method
Method
Respondents
Respondents
Respondents: Experience by Role in Wraparound Implementation
Respondents: Experience by Role in Wraparound Implementation
CSWI Results: Averages by Theme for NV
CSWI Results: Averages by Theme for NV
Cross-Site Comparison: Nevada (site 2) versus 5 other Wrap initiatives
Cross-Site Comparison: Nevada (site 2) versus 5 other Wrap initiatives
Results
Results
Other areas of relative strength: Moderate development
Other areas of relative strength: Moderate development
Other areas of relative strength: Moderate development
Other areas of relative strength: Moderate development
Areas of modest development
Areas of modest development
Least development
Least development
Results: Big Picture summary
Results: Big Picture summary
Results: Positive Comments from Respondents
Results: Positive Comments from Respondents
Results: Positive Comments (continued)
Results: Positive Comments (continued)
Results: Comments about Challenges
Results: Comments about Challenges
So: What are next steps
So: What are next steps
Next steps for the Consortium
Next steps for the Consortium

: Youth and Family Supports Study. : Eric Bruns. : Youth and Family Supports Study.ppt. zip-: 551 .

Youth and Family Supports Study

Youth and Family Supports Study.ppt
1 Researching Wraparound in Nevada Overview of the Youth and Family

Researching Wraparound in Nevada Overview of the Youth and Family

Supports Study Funded by the National Institute of Mental Health

State MH Consortium Meeting May 22, 2008 Reno, Nevada Eric J. Bruns, University of Washington Ramona Denby Brinson, University of Nevada, Las Vegas Michelle Ramey, University of Nevada, Las Vegas ebruns@u.washington.edu Ramona.denby@unlv.edu Michelle.Ramey@unlv.edu

1

2 Overview of this Presentation

Overview of this Presentation

Background: What works in childrens mental health? The role of Wraparound in achieving positive outcomes for youth and families What does it take to implement wraparound? Research on wraparound fidelity The Nevada Youth and Family Supports Study Study goals Data still to come Opportunities for Nevada Data from the Study so far: Implementation of Wraparound in Nevada What next?

2

3 What is an Evidence Based Practice

What is an Evidence Based Practice

A process of applying scientific knowledge about service practices to the situation of an individual child and family Treatment procedures that have been shown to be effective through scientific evidence of some level of robustness*

*From Bruns, Hoagwood et al. (in press). State implementation of evidence based practice, Part 2: Recommendations for research and policy. Journal of the American Academy of Child and Adolesc. Psychiatry.

3

4 We have treatments with evidence for effectiveness for

We have treatments with evidence for effectiveness for

Anxious or Avoidant Behaviors Attention and Hyperactive Disorders Autistic Spectrum Disorders Disruptive and Oppositional Behaviors Self-harming Behaviors

Assaultive and Aggressive Behaviors Sexually Aggressive Behaviors Traumatic Stress Interpersonal problems Substance use Delinquent behavior History of abuse and neglect

4

5 Unfortunately, major barriers to using EBPs in real world practice

Unfortunately, major barriers to using EBPs in real world practice

Complexity of child and family needs Multiple and overlapping child problem areas Unmet basic family needs Many providers, many requirements, little coordination Lack of full engagement and partnership with families Families are overwhelmed, do not feel their priority needs are being addressed Leads to treatment dropouts, missed opportunities for positive change, bad outcomes

5

6 Theory of change: Why wraparound may be critical to positive outcomes

Theory of change: Why wraparound may be critical to positive outcomes

Positive

Outcomes!

Getting Support

Achieving Goals

Teamwork & coordination

Optimism & Hope

Better plans

Better follow through

Self- Efficacy

Facilitator, Team, Flex funds, Service array

Family Drives the process

Natural supports

6

7 Promising Outcomes for Communities using the Wraparound Process

Promising Outcomes for Communities using the Wraparound Process

7

8 Outcomes  Wraparound Milwaukee

Outcomes Wraparound Milwaukee

Average daily Residential Treatment population reduced from 375 placements to 70 placements Psychiatric Inpatient Utilization reduced from 5000 days per year to under 200 days (average LOS of 2.1 days) Reduction in Juvenile Correctional Commitments from 325 per year to 150 (over last 3 years)

8

9 Results from Nevada: Living in less restrictive, more community based

Results from Nevada: Living in less restrictive, more community based

settings

9

10 Results from Nevada: Functioning better in the community

Results from Nevada: Functioning better in the community

10

11 Results from Oklahoma: Getting to permanency

Results from Oklahoma: Getting to permanency

11

12 Results from Oklahoma Supporting re-integration of adult prisoners

Results from Oklahoma Supporting re-integration of adult prisoners

12

13 OK, so the theory of change makes good sense

OK, so the theory of change makes good sense

Families like wraparound The model is being better understood. The research base continues to grow So, what is the challenge?

13

14 A National Review of Wraparound Teams Showed (Walker, Koroloff, &

A National Review of Wraparound Teams Showed (Walker, Koroloff, &

Schutte, 2003)

Less than 1/3 of teams maintained a plan with team goals Less than 20% of teams considered >1 way to meet a need Only 12% of interventions were individualized or created just for that family

All plans (out of more than 100) had psychotherapy Natural supports were represented minimally 0 natural supports 60% 1 natural support 32% 2 or more natural support 8% Effective team processes were rarely observed

14

15 Hospitable

Hospitable

System (Policy and Funding Context)

Supportive

Organization (lead and partner agencies)

Effective

Team

15

16 System and organizational supports for wraparound

System and organizational supports for wraparound

Community Partnership. Community ownership of wraparound is built through collaborations among key stakeholder groups. Collaborative Action. Stakeholders involved in the wraparound effort take concrete steps to develop concrete policies, practices and achievements. Fiscal Policies and Sustainability. The community has developed fiscal strategies to meet the needs of children participating in wraparound and methods to collect and use data on expenditures.

16

17 System and organizational supports for wraparound

System and organizational supports for wraparound

Access to Needed Supports & Services. There are mechanisms for ensuring access to the services and supports that teams need to fully implement their plans Human Resource Development & Support. The system supports wraparound staff and partner agency staff to fully implement the wraparound model. Low caseloads The right job descriptions Training and coaching Good supervision, etc Accountability. The community has mechanisms to monitor wraparound quality and outcomes.

17

18 Monitoring quality of implementation of child and family teams

Monitoring quality of implementation of child and family teams

Have facilitators and team members fill out activity checklists Look at plans of care and meeting notes Sit in on and observe team meetings Ask the people who know parents, care givers, youth, facilitators, program heads

18

19 Wraparound Fidelity Assessment System

Wraparound Fidelity Assessment System

WFAS

TOM Team Observation Measure

WFI-4 Wraparound Fidelity Index

CSWI Community Supports for Wraparound Index

DOC - Document Review Measure

WFI-4

TOM

Doc Review

CSWI

19

20 Summary: What Leads To Outcomes

Summary: What Leads To Outcomes

Improved Child and Family Outcomes

Program and System Supports

Sticking to the wrap principles in service delivery

Training, Coaching, and Quality Assurance

20

21 A summary of research on wraparound implementation

A summary of research on wraparound implementation

There are connections between system support for wraparound implementation and fidelity There are connections between wrap fidelity and child and family outcomes We are beginning to get a sense of what high fidelity is in terms of scores on tools like the WFI BUT: The research is still preliminary, and the field is looking for additional evidence

21

22 Studying Wraparound Implementation in Nevada

Studying Wraparound Implementation in Nevada

22

23 The Outcomes of Wraparound in Nevada Study

The Outcomes of Wraparound in Nevada Study

The first NIMH-sponsored controlled research study of wraparound Examines the differences in outcomes, treatment processes, and costs of wraparound vs. case management Tests psychometrics of the Wraparound Fidelity Index and other fidelity tools A chance to use data on treatment processes, costs, and outcomes to inform implementation of services for youth with SED in Nevada

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24 Major Research Questions

Major Research Questions

Does implementing wraparound for a youth with SED result in a different service process than implementing intensive CM? Does the wraparound process lead to better outcomes? What are the costs of the two models? How important is wraparound fidelity to achieving outcomes?

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25 Study population

Study population

150 children and youth (age 6-17) with SED that requires intensive intervention Fee for service Medicaid eligible N=75 assigned to Wraparound condition as delivered by WIN and CCS N=75 assigned to CM delivered by Mojave

25

26 What data is the Youth and Family Supports Study providing

What data is the Youth and Family Supports Study providing

Child Behavior and Functioning Strengths and Difficulties Questionnaire (SDQ) Child and Adolescent Functional Assessment Scale (CAFAS) Child Status Report Residential Setting; Child Welfare, School, and Juvenile Justice Outcomes* Services received Services Assessment for Children and Adolescents Case Management Function Form Service processes and satisfaction Parent and Youth Satisfaction Questionnaires Working Alliance Inventory Family Empowerment Scale Glisson Organizational Social Context Scale * Also being collected via admin. data from DCFS, DJJS, CCPSS

26

27 Additional data from the Youth and Family Supports Study

Additional data from the Youth and Family Supports Study

Fidelity to the wraparound model From interviews of the WFI From team observations from the TOM System support for wraparound Community Supports for Wraparound Inventory (CSWI) Connections to resources who is on their team? What is in their plan? Whether services are making a difference in areas that matter to families (e.g., optimism; level of empowerment; lost days at work)

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28 Progress report

Progress report

28

29 Study Enrollment to date

Study Enrollment to date

29

30 Characteristics of YFSS Participants

Characteristics of YFSS Participants

N=48 total (41 active) cases with baseline data collection completed as of April 2008

30

31 Demographics

Demographics

Male = 22 (46%) Female = 26 (54%) Age Mean = 11.42 (SD = 3.35) Range = 6-17 Race African American = 16 (36%) White = 12 (27%) Hispanic = 7 (16%) Mixed Race = 7 (16%) AA & White = 3; AA & Hispanic = 4 Native American = 1 (5%) Biological parents w/parental rights = 15 (31%)

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32 Referral and study information

Referral and study information

Referral source (to services) Child welfare = 37 (79%) Self = 7 (15%) School = 2 (4%) Mental health agency/provider = 1 (2%) Language spoken at home (other than English) Spanish = 2 (4%) Assignment to services ICM = 20 WIN = 20 CCS = 8

32

33 Placement and Placement History

Placement and Placement History

Current placement Foster Care = 18 (44%) Biological or Adoptive Parents = 11 (27%) Group Home or Shelter = 5 (12%) Relative = 5 (10%) Residential job corps/vocational = 2 (5%) Previous 6 mos Group Home or Shelter Care = 8 (20%) Residential Treatment = 4 (10%) Psychiatric Hospital = 3 (7%)

33

34 DSM Diagnoses assigned (N=30)

DSM Diagnoses assigned (N=30)

Adjustment Disorders = 10 (33%) ADHD = 8 (26%) Mood Disorders (incl. Depression/Bipolar) = 7 (22%) Disruptive disorders (incl. ODD/CD) = 7 (22%) Post Traumatic Stress = 4 (13%) Attachment Disorders = 2 (7%) Developmental Disorders = 2 (7%) Substance Abuse Disorder = 1 (3%) Learning Disorder = 1 (3%) Psychotic Disorder = 1 (3%)

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35 Number of Diagnoses Assigned (N=30)

Number of Diagnoses Assigned (N=30)

35

36 CAFAS Functioning Subscales: Percent of youth with moderate to

CAFAS Functioning Subscales: Percent of youth with moderate to

severe needs

36

37 Findings on Wraparound Implementation in Nevada from the YFSS

Findings on Wraparound Implementation in Nevada from the YFSS

37

38 Baseline Fidelity data assessment (2006-07)

Baseline Fidelity data assessment (2006-07)

Vision for the project: Inform high quality practice, Create a culture in which data is used to inform decision making, Ensure a better understanding of wraparound on the part of families and providers, and Help make the case for better support for wraparound implementation in Nevada.

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39 Baseline Fidelity data assessment (2006-07)

Baseline Fidelity data assessment (2006-07)

Methods: Random sample of N=90 youth drawn from WIN and CCS in Clark Co Data collection completed for: Wraparound Fidelity Index (WFI) N=59 youth 139 interviews completed across the 3 respondent types Team Observation Measure (TOM) N=27 team meetings observed by UNLV and DCFS staff Document Review Measure (DRM) N=65 case files reviewed by UNLV and DCFS staff

39

40 Results of Fidelity Assessment: Strengths of wraparound implementation

Results of Fidelity Assessment: Strengths of wraparound implementation

Cultural & Linguistic Competence. WIN and CCS teams have shown respect for the values, preferences, beliefs, culture, and identity of the child and family, and their community. Items for this indicator were extremely high across all instruments used. Collaborative Efforts. Those serving on WIN and CCS wraparound teams demonstrate cooperation and shared responsibility for developing, implementing, monitoring, and evaluating wraparound plans. In particular, effective team brainstorming of strategies was noted in the WFI. Persistence. Data indicate WIN and CCS wrap teams persist in working towards goals included in the wraparound plan, despite challenges presented by enrolled families. Teams successfully maintain youth in the community, and ensure some members of the team will be available after formal wraparound is finished. Other strengths Working to keep the youth in the least restrictive environment, encouraging youth and family voice, maintaining a positive team culture and having team members who share responsibility for designing and implementing the child and familys plan

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41 Results of Fidelity Assessment: Needs for improvement

Results of Fidelity Assessment: Needs for improvement

Natural Supports. Seeking out and encouraging full participation of individuals from family members networks of interpersonal and community relationships. Team Based. The family and youth are not typically picking who will be on their child and family team, and there are unclear roles for natural & community supports on teams. Outcome Based Process. WIN and CCS wrap teams are not consistently tying the goals and strategies of the wraparound plan to measurable indicators, measuring progress, using assessment of progress to guide follow-through. Crisis Planning. Many records did not include crisis plans that based on functional assessments for the children and youth and did not have strategies for preventing the crisis or detailed steps to be taken. Other needs for improvement Strategizing ways to involve the youth and family in community activities Transition planning Clarity of roles between DCFS and child welfare staff

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42 Summary scores: Wraparound Fidelity Index Compared to another state +

Summary scores: Wraparound Fidelity Index Compared to another state +

high fidelity benchmarks

42

43 More Results on Wrap Implementation: From the Community Supports for

More Results on Wrap Implementation: From the Community Supports for

Wraparound Inventory

43

44 The Community Supports for Wraparound Inventory

The Community Supports for Wraparound Inventory

The 40 items are grouped within 6 themes: Community partnership Collaborative action Fiscal policies Service array Human resource development, and Accountability Respondents complete the 40 items by rating the development of supports in their community or program on a 5 point scale 0 = least developed and 4 = fully developed

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45 Method

Method

31 stakeholders in the Nevada system of care were identified and invited to complete the CSWI These stakeholders were sent a link to a web survey version of the CSWI 22 nominated respondents completed the CSWI (71%), 4 declined to complete the CSWI (13%), and 5 did not respond (16%)

45

46 Respondents

Respondents

Mean total experience with wraparound = 6.6 years Mean years in current wrap program = 3.6 years

46

47 Respondents: Experience by Role in Wraparound Implementation

Respondents: Experience by Role in Wraparound Implementation

Role

Number*

Mean Experience in Role

Family/youth on team

Natural support on team

Parent partner/advocate

Facilitator/Care co-ord.

Professional on team

Wrap supervisor/coach

Trainer/Consultant

Manager/administrator

Higher admin/Policy

Researcher

1.5 years

4

5.8 years

8

6.0 years

7

5.3 years

9

4.1 years

12

6.5 years

8

3.3 years

9

2.2 years

10

5.2 years

4

5.8 years

4

*This column total sums to more than total respondents due to people having filled multiple roles over time.

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48 CSWI Results: Averages by Theme for NV

CSWI Results: Averages by Theme for NV

Least developed

Fully developed

Midway

48

49 Cross-Site Comparison: Nevada (site 2) versus 5 other Wrap initiatives

Cross-Site Comparison: Nevada (site 2) versus 5 other Wrap initiatives

49

50 Results

Results

Greatest relative strength**

Item

Mean Rating

2.1 Community Principles and Values

2.4

50

51 Other areas of relative strength: Moderate development

Other areas of relative strength: Moderate development

Item

Mean Rating

5.4 Professional development

2.11

5.5 Supervision

2.11

1.1 Community team

2.09

1.2 Empowered community team

2.09

2.3 Proactive Planning

2.06

2.8 State interface

2.06

2.5 Partner agency staff preparation

2.06

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52 Other areas of relative strength: Moderate development

Other areas of relative strength: Moderate development

Item

Mean Rating

2.2 High-level leadership

1.89

2.7 Single plan

1.89

5.3 Caseload sizes

1.89

1.5 Agency support

1.86

3.6 Sustained funding

1.82

5.2 Agency job expectations

1.76

5.1 Wraparound job expectations

1.76

2.6 Information sharing

1.74

1.3 Family voice

1.73

4.1 Program access

1.72

6.2 Range of outcomes

1.65

6.1 Outcomes monitoring

1.63

52

53 Areas of modest development

Areas of modest development

Item

Mean Rating

6.1 Outcomes monitoring

1.63

6.3 Wraparound quality

1.59

2.4 Joint action steps

1.59

1.7 Community representativeness

1.55

6.4 Plan fulfillment

1.53

4.5 Service/support quality

1.53

4.2 Service/support availability

1.50

4.4 Choice

1.50

3.5 Fiscal flexibility

1.47

5.6 Compensation for wraparound staff

1.41

6.6 Satisfaction monitoring

1.40

4.3 Building natural and community supports

1.39

53

54 Least development

Least development

Item

Mean Rating

6.5 Grievance procedure

1.29

1.6 Community stakeholders

1.23

4.6 Crisis response

1.22

6.7 Addressing barriers

1.20

3.1 Fiscal understanding

1.13

3.2 Removing fiscal barriers

1.07

3.3 Collective fiscal responsibility

0.88

3.4 Fiscal monitoring

0.87

1.4 Youth voice

0.86

54

55 Results: Big Picture summary

Results: Big Picture summary

WIN programs strengths are in the first two themes Community Partnership (except youth voice) and Collaborative Activity Least developed area: fiscal policies and sustainability

55

56 Results: Positive Comments from Respondents

Results: Positive Comments from Respondents

Foundations of collaboration All agencies are at the table talking. When the systems work together, family and children benefit. In addition, when the agencies are committed to the wraparound process, work satisfaction increases, positive collaborative efforts increase and again, the family and children benefit The wraparound model Using a team approach--Family driven, strength based, family voice and choice The strength-based approach, family voice and choice has empowered the families I've provided services. Along with The Child and Family Team Approach.

56

57 Results: Positive Comments (continued)

Results: Positive Comments (continued)

Building capacity for wraparound practice Even without good system supports, wraparound appears to show good outcomes - if there is good supervision of staff that ensures the highest fidelity Building system capacity There is a stable infrastructure for the wraparound program. There are beginning efforts to implement continuous quality improvement strategies for wraparound. I have seen through the past four years more support to really do the model with our families. More people know about wraparound.

57

58 Results: Comments about Challenges

Results: Comments about Challenges

Fiscal issues, particularly lack of funding for support services Lack of funding for Family Support services. Funding for non-governmental organizations continues to be a problem. Fiscal policies and practices present barriers to effective implementation of wraparound. There is a grossly inadequate capacity to provide the supportive services necessary for wraparound (therapies, psychiatric services, mentoring, behavioral support services, etc.) Collaboration between agencies Cross-Agency collaboration and full understanding of the wraparound process.. Conflicting philosophies among public agencies. Lack of understanding of what the wraparound process is both in public and private system partner agencies and therefore, inadequate buy-in and support for the process. Getting everyone's buy in and to agree on one process in implementation.

58

59 So: What are next steps

So: What are next steps

The Youth and Family Supports Study will continue to provide information on: Wraparound Implementation and Fidelity Satisfaction and services being received Outcomes for 150 youth in the system in the areas of home, community, and school Progress being made by youth and families toward their wraparound goals, permanency, and other outcomes Costs of serving youth and cost-savings Question: What additional information will the Consortium benefit from? By when? Formatted how?

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60 Next steps for the Consortium

Next steps for the Consortium

When considering how best to support implementation or expansion of wraparound, consider: Leadership Infrastructure and oversight Fiscal and other Policies Collaboration across stakeholders and agencies Social Marketing Professional development: Support for high quality supervision, training, and coaching of staff

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