Wraparound Implementation Research Articles

Connecticut university establishes Innovations Institute

The University of Connecticut School of Social Work (UConn SSW) announced last month the arrival of its Innovations Institute. The institute extends the UConn's commitment to social, racial, and economic justice and the improvement of human well‐being nationwide, the campus news website, UConn Today, reported on Dec. 8. To fulfill its mission, the UConn SSW has deep and long‐standing partnerships with Connecticut state agencies that serve children, youth, and their families, including the departments of social services, children and families, mental health and addiction services, and the Connecticut Office of Early Childhood. Through these robust partnerships, UConn provides research, implementation, and evaluation of evidence‐based programs and policies that serve children, youth, and families across the state, officials stated. The Innovations Institute is comprised of 41 faculty and staff and six national centers that are formerly affiliated with the University of Maryland. These centers include the Peer TA Network; the National SOGIE Center; the National Wraparound Implementation Center; the National Quality Improvement Center on Family‐Centered Reunification; the National Quality Improvement Center on Tailored Services, Placement Stability, and Permanency for Lesbian, Gay, Bisexual, Transgender, Questioning and Two‐Spirit Children and Youth in Foster Care; and the Center of Excellence on LGBTQ+ Behavioral Health Equity, the online campus news site, UCONN Today reported on Dec. 8. Innovations Institute builds research‐based, inclusive, culturally responsive, and transformative child‐, youth‐ and family‐serving systems and services, and develops the capacity of the workforce within these systems. They are currently partnering with state and local governments, health care providers, youths and their families, and community‐based organizations in 42 states across the U.S.

Influences of Inner and Outer Settings on Wraparound Implementation Outcomes

In recent years, implementation researchers have focused on associations among organizational characteristics (inner settings), policy and funding drivers (outer setting), and implementation outcomes. The current study evaluated the influence of outer setting drivers on implementation of Wraparound care coordination for youth with complex behavioral health needs. Data were drawn from two sources. First, we examined the impact of outer setting drivers on Wraparound implementation by comparing Wraparound implementation in states that used Community Mental Health Centers (CMHCs) versus Care Management Entities (CMEs). Wraparound fidelity data were compiled for a sample of 1174 direct service providers within 9 states. Second, we compared workforce development efforts across CMHCs and CMEs within a separate sample of 813 administrators and practitioners. Results of multilevel models found that CMEs were associated with higher overall fidelity scores than CMHCs [b = .219, t(5.47) = 3.26, p = .020] even after accounting for state-level covariates and the clustering of individual practitioners within organizations. Furthermore, compared with CMHC staff, those employed by CMEs reported higher competence with the Wraparound model and attended more Wraparound-related trainings. Staff employed by CMHCs were more likely to change practices than their CME counterparts. These findings suggest possible influences of outer settings on Wraparound implementation. The unique policies and procedures associated with CMEs may have helped facilitate practice fidelity among staff, promoted competence, and required fewer practice changes to implement Wraparound. Such findings underscore the importance of policy and fiscal factors in implementation of Wraparound and other evidence-based strategies.

A Longitudinal Evaluation of Wraparound’s Impact on Youth Mental Health Service Use

Wraparound is a care coordination model that has shown effectiveness for serving children and youth with significant emotional and behavioral health needs and their families. The current study evaluates a statewide wraparound demonstration with the goals of reducing the use of residential care and increasing access to outpatient mental health services among youth at risk of residential placement. More than 5 years of linked public systems data were analyzed using longitudinal panel data modeling to estimate wraparound treatment effects on service use over time. Findings show that wraparound enrollment decreased the use of residential treatment and increased the use of outpatient therapy, consistent with the goals of the demonstration. Implications are discussed for wraparound’s effectiveness as a statewide care coordination model, the importance of quality implementation of wraparound, and the current study’s methodological contributions to the wraparound literature.

Changing Organization Culture: Data Driven Participatory Evaluation and Revision of Wraparound Implementation

Family members and professionals in a Substance Abuse and Mental Health Services Administration Children's Mental Health Systems of Care Initiative in Houston, Texas conducted a participatory evaluation to examine wraparound implementation. Results guided systematic, theory-based program revisions. By focusing through empirically derived frameworks for implementation, the evaluation team identified and generated useful data sources to support and improve wraparound provision. Despite working with a more diverse population in which youth displayed more severe behaviors than in similar grants, after 18 months more families received service and outcomes improved as fidelity scores advanced above the national mean.

The implementation of wraparound in California's Title IV-E Child Welfare Waiver Demonstration Project

Understanding the implementation of Wraparound in child welfare is essential to its continued use in the field. The purpose of this study was to understand the implementation of Wraparound in regard to organizational and systems-related factors and contexts. Wraparound was implemented and evaluated in five counties as part of California's Title IV-E Child Welfare Waiver Demonstration Project, from 1999 to 2004. The three areas of inquiry include the models of Wraparound used, important aspects of the implementation efforts, and the interaction between the principles and values of Wraparound and those of the child welfare system. A multiple case study design provided the structure for data collection and analysis. Focus groups with a convenience sample of administrators and direct-service staff from the public agencies and private community-based agencies implementing Wraparound were conducted annually. While the Wraparound models were similar in configuration there were also unique characteristics that developed in response to local conditions. Issues and solutions emerged regarding referrals and case closures, staffing and training, management information systems, funding, and contextual factors. The values and principles of the child welfare departments, group home providers, and families interacted with the values and principles of Wraparound. The results highlight the importance of organization and systems-level characteristics. Building on the solutions developed in California will help to ensure the sustainability of Wraparound.

Perceptions of Family Environment and Wraparound Processes: Associations with Age and Implications for Serving Transitioning Youth in Systems of Care

Addressing the unique needs of youth transitioning to adulthood has long been viewed as a priority in implementation of systems of care (SOCs) and wraparound. Developmental research and "practice-based evidence" suggest that there are differences between transitioning youth and their younger peers in family environment and wraparound team processes. Although these differences are thought to have significant implications for wraparound practice, few studies have examined them empirically. The present research involves two studies examining differences across several age cohorts (i.e., 10–12, 13, 14, 15, 16–17 year-olds) ranging from early adolescent to transitioning youth in: (1) caregiver perceptions of role-related strain and family environment quality, and (2) facilitator, caregiver, and youth perceptions of wraparound processes. In Study #1, older age was associated with higher levels of caregiver strain. In Study #2, age was associated with differences between youth and other team members' perceptions of wraparound processes, such that older youth perceived teams as less cohesive than others on their teams. These findings suggest that transitioning youth and their families merit special consideration in wraparound implementation and underscore the importance of considering the perceptions of transitioning youth in system change and practice improvement efforts (192 words).

Connecting the Dots: Stages of Implementation, Wraparound Fidelity and Youth Outcomes

Several necessary system and organizational support conditions for wraparound have been identified (Walker et al. 2003). Yet, the relationship between these necessary system level conditions and wraparound fidelity has only recently begun to be examined. Similarly, few studies have included a measure of wraparound fidelity when examining the relationship between wraparound implementation and youth outcomes. The statewide implementation of a wraparound demonstration grant offers the opportunity to explore these relationships and to identify factors that predict improvement in functioning for youth receiving wraparound. Findings suggest that significant relationships exist between (1) the stage of development of necessary support conditions for wraparound and wraparound fidelity and (2) wraparound fidelity and improvement in youth outcomes. Specific elements of wraparound (i.e., outcomes based and community based) and baseline needs and strengths (e.g., high levels of anxiety and conduct issues, poor functioning at home and in school, judgment, and risks) were found to predict a reduction in youth needs. Other unexpected relationships between youth outcomes and the cultural competence element of wraparound and being multi-racial were also discovered. These findings reinforce the importance of supporting high fidelity wraparound for youth and their families in a recovery focused behavioral health system.

Using a Theory of Change to Drive Human Resource Development for Wraparound

Achieving coherence and integration across staff professional development activities is facilitated when training, coaching and staff evaluation are guided by a clearly articulated program theory or “theory of change” that describes how skillful practice promotes desired outcomes. We focus on a theory of change for wraparound, a widely implemented approach to providing community-based care for children with high levels of mental health and related needs. Training, coaching and staff evaluation efforts within wraparound programs have typically been linked only very loosely to theory. We argue that wraparound’s unique history allowed it to evolve with limited theoretical grounding, and we then describe a theory of change for wraparound, focusing on the major causal routes that are hypothesized to lead to outcomes. Finally, we provide an extended illustration of how the theory can provide the basis for a coherent and integrated approach to developing the skills and capacities of staff members playing key roles in wraparound implementation.

National Trends in Implementing Wraparound: Results from the State Wraparound Survey

The wraparound process has been promoted in the children’s services field as a mechanism to achieve collaborative service planning and delivery for families of young people with complex emotional and behavioral needs that span multiple agencies. We compared results of two surveys of state children’s mental health directors, completed in 1998 and 2008, to derive estimates of the extent of wraparound implementation in the United States and to better understand trends in how wraparound has been implemented and supported over time. Results from 2008 found that 88% of states reported having some type of wraparound program that conformed to the definition and provided an estimate of 100,000 children and families served via wraparound in that year. Between 1998 and 2008, states reported increased application of wraparound standards, a greater number of agencies involved in wraparound initiatives, and more formal evaluations of wraparound initiatives. Results provide substantiation of the widespread implementation of wraparound implementation in the United States, and evidence that the model is becoming more consistently supported by formal implementation structures over time.

The Impact of Child and Family Team Composition on Wraparound Fidelity: Examining Links Between Team Attendance Consistency and Functioning

Although a growing body of literature has examined wraparound implementation and fidelity, child and family team (CFT) members’ levels of participation and the consistency of their attendance have not been systematically examined. This study explored the relationship between CFT member attendance consistency and the fidelity of wraparound team level implementation processes in a System of Care (SOC). Specifically, utilizing Participant Rating Form (PRF) data collected from caregivers, facilitators, youth, supportive persons, and service providers, as well as meeting attendance records, the relationship between team attendance consistency and fidelity of wraparound implementation was explored. Records for 88 teams, with a total of 2,643 members’ ratings of CFT meetings between 2004 and 2009, were examined. Analyses indicate that the structural team factors of attendance consistency and mean team members present relate to CFT members’ ratings of team functioning and the degree to which meeting processes are consistent with the tenets of wraparound. Team attendance variables related to the views of meeting functioning by facilitators, service providers, and caregivers, the individuals most often responsible for implementation of the plan of care, but not ratings by youth or supportive persons. These findings have implications for policy and the successful implementation of wraparound, underscoring the relevance of attending to and tracking the composition of the CFT and more actively encouraging consistent meeting attendance. Results also highlight the need to measure structural variables that may have salience in fidelity and implementation assessments and, more globally, the effectiveness of SOCs.

Implementation Research and Wraparound Literature: Building a Research Agenda

We used the framework identified by the National Implementation Research Network’s (NIRN) analysis of 35 years of implementation outcomes literature from diverse fields of endeavor to review the current state of wraparound implementation research. Model definition, model fidelity and intervention outcomes were areas of relatively greater development, while target population, theory base and theory of change, organizational context and readiness, staff selection, training, supervision or coaching, purveyor selection, and program installation were less examined or even overlooked. We conclude with suggestions for building a research agenda on wraparound implementation.

Integrating Wraparound into a Schoolwide System of Positive Behavior Supports

We describe the structure for implementation of the wraparound process within a multi-tiered system of school wide positive behavior support (SWPBS) to address the needs of the 1-5% of students with complex emotional/ behavioral challenges. The installation of prerequisite system features that, based on a 3 year demonstration process, we consider critical to full operation of the Tier 3 wraparound intervention within a system of SWPBS is also described. We include examples of system implementation benchmarks that occur concurrently with student outcome data and are logically linked to full operation and sus- tainability of wraparound implementation. Challenges surrounding implementation and proposed advancements are also discussed.

The importance of context in fostering responsive community systems: Supports for families in systems of care.

The importance of helping families of children with severe emotional disturbances (SED) connect with informal or natural supports-that is, individuals who are part of their ongoing communities and daily lives-has been widely recognized. Utilization of informal supports has thus become a core element within systems of care (SOCs) designed to improve services for children with SED and their families. However, research demonstrates that implementation of wraparound, the key practice approach within SOCs, often does not include involvement of informal supports. Using a measure of social connectedness (SC), developed to augment the instruments used for the SOC national evaluation, this study assessed parents' and caregivers' views of their connections to and support from their community within a SOC. Overall, parents and caregivers reported low levels of support across multiple sources as well as a desire for more support. Greater levels of perceived support related positively to caregiver strain, types of and satisfaction with services received, and views of their communities as supportive and safe. Greater attention to families' contexts and the identification of effective ways to connect families to their communities are recommended.

Is It Wraparound Yet? Setting Quality Standards for Implementation of the Wraparound Process

The wraparound process has increasingly been used as a mechanism to plan and coordinate services for children with behavioral health needs and their families. This has led to growing interest in assessing wraparound implementation against standards for quality. However, there has been little consideration of how best to establish such benchmarks or guidelines. Using both a norm-referenced and criterion-referenced approach, this study established preliminary criteria for assessing the adequacy of wraparound implementation using the Wraparound Fidelity Index, version 3, a multi-informant interview that assesses conformance to wraparound principles. The evaluation system was then applied to ten wraparound programs and 11 different study samples assessed via the Wraparound Fidelity Index version 3 in research studies. The system was constructed to discriminate different wraparound conditions assessed in research studies while still being attainable by the ten established wraparound programs. Implications for evaluating wraparound programs and for setting fidelity benchmarks in behavioral health services research are discussed.

Who Administers Wraparound?

The wraparound care management process has been cited as a promising means for making evidence-based treatments relevant and accessible to youth with mental health needs and their families. However, there has been little research on the background and training of providers who participate on wraparound teams. In the current study, the authors examined the prevalence of wraparound implementation nationally in systems of care and the background,training,organizational supports, and perceptions of evidence-based treatments (EBTs) for professionals who implement wraparound. Results suggest that wraparound implementation is common across communities and that wraparound providers are different from other professionals.They are,for example,less likely to have an advanced degree, more likely to have received their training from agency inservices, less likely to receive manuals with their training, and more likely to report fully implementing treatment protocols.Wraparound providers are also more likely to report that their agency or organization mandated implementation of EBTs. Results provide several implications for wraparound model specification, development of quality assurance supports, and a need for higher education to better orient trainees to models and philosophies such as wraparound.

Grounded Theory and Backward Mapping: Exploring the Implementation Context for Wraparound

Within children's mental health, there is an increasing demand for wider implementation of wraparound and other interventions that can provide comprehensive, individualized, family-driven care. Unfortunately, implementation has proven difficult because these approaches do not necessarily flourish within traditionally organized agencies and systems. This has highlighted the need for information about how mental health agencies and systems must evolve if they are to provide a hospitable implementation environment for these interventions. A first step in developing this information is through research that advances conceptual and theoretical understanding of the impact of contextual factors on implementation. At the same time, there is an immediate need for practical information to guide decision making and policy development in settings where implementation is being undertaken. This article describes a study of wraparound implementation that used a combination of qualitative strategies to meet both of these needs simultaneously. It is argued that these strategies are particularly well suited to the study of emerging practices that reflect-and help drive-transformation in mental health systems.

Relations Between Program and System Variables and Fidelity to the Wraparound Process for Children and Families

Relations Between Program and System Variables and Fidelity to the Wraparound Process for Children and Families

Relations Between Program and System Variables and Fidelity to the Wraparound Process for Children and Families

Past research and experience have indicated that characteristics of organizations and service systems influence the quality of mental health services delivery. The study aimed to illuminate such associations by examining the relationship between a set of program- and system-level variables and fidelity to the wraparound model for children and families. A measure of fidelity to the wraparound process for children and families (the Wraparound Fidelity Index) was administered to families receiving services in eight mental health agencies across the United States. Program administrators at each agency also completed by telephone a standardized interview for assessing program and system conditions hypothesized to influence quality of implementation (Program Administrator version of the Wraparound Fidelity Index). Regression analyses were used to assess the relationship between program and system variables and fidelity. Results of interviews with program administrators revealed substantial variation across programs in the number and type of program and system supports for wraparound implementation. Regression analyses found a significant association between the number of organizational and system supports and Wraparound Fidelity Index scores. Results support the hypothesized relationship between program and system conditions and the quality of service delivery. Results also highlight the importance of engineering the system and organizational context (maintaining low caseload sizes, establishing interagency partnerships, and implementing accountability mechanisms) in order to provide a solid foundation for high-quality wraparound to children and families.

Partnership with parents and disabled children. HIA of the All-Inclusive Wraparound Project for children with a disability

The All-Inclusive Wraparound Scheme seeks to develop new ways of multidisciplinary, interagency working that will make a difference to the lives of children with disabilities (aged 0–18 years) and their families and carers across the Southern Health and Social Services Board in Northern Ireland. A concurrent HIA was undertaken with the aims of identifying the positive and negative health impacts, producing clear recommendations to improve the service and informing the development of an evaluation and monitoring framework. Eight community-based projects linked to 15 partners were involved in the HIA. Health and social services, education, the Library Board, voluntary sector community groups, parents and children all took part. It was concluded that there was a need for better information for parents to enable them to access services. Partnership working with parents and between agencies needed to be improved and parents and professionals on partnership working. The handover between services at transition from preschool to school-age and from school-age to adult services needed to be better planned. Conducting a HIA early in the implementation of Wraparound has enabled the project to take account of more perspectives and influence the delivery of services for children with a disability.