Wraparound Process Research Articles

Measurement Characteristics of the Wraparound Fidelity Index Short Form: Results from a Statewide Implementation.

Implementation fidelity has been an important issue in the service provision and associated outcomes of Wraparound, an intensive, individualized care planning process that uses a team-based approach to integrate youth into the community to minimize the need for intensive, institutional services. In response to the growing need to monitor fidelity to the Wraparound process, a variety of instruments have been created and tested. In this study, the authors present the results of several analyses designed to better understand the measurement characteristics of the Wraparound Fidelity Index Short Form (WFI-EZ), a multi-informant fidelity instrument. The results from our analysis of 1027 WFI-EZ responses indicate that the internal consistency of the instrument is very good, although the negatively worded items did not appear to function as well as positively worded items. Results from two confirmatory factor analyses were unable to validate the original domains identified by the instrument developers, but for certain outcomes the WFI-EZ demonstrated deseriable predictive validity. Preliminary evidence is also provided that WFI-EZ responses likely differ by respondent type. We conclude by discussing the implications of using the WFI-EZ in programming, policy, and practice considering the findings of our study.

Education-Centred Formal Wraparound Services in Support of School-Aged Students With Complex Support Needs: A Systematic Review

AbstractThe aim of this systematic review was to map the peer-reviewed literature (2009–2019) relating to school involvement with wraparound models in the support of students with complex needs. Specific research questions addressed explored the evidence base of the efficacy of wraparound with these students and barriers and enablers in the provision of wraparound services. Database searches were conducted and a total of 50 articles were identified. The analysis revealed eight different aspects of wraparound efficacy, with mixed results. Nine factors were identified as having a positive enabling, or disabling, effect on the provision of effective wraparound services. The wraparound programs were varied in their nature and in their successful implementation, with time to allow the program to mature and adherence to the 10 principles of the wraparound process emerging as enabling factors for wraparound success.

Understanding Racial-Ethnic Disparities in Wraparound Care for Youths With Emotional and Behavioral Disorders.

Systems of care (SOCs) were developed to increase access to and quality of care for children with emotional and behavioral difficulties and their families through the provision of coordinated, community-based, culturally competent, family-driven services. SOCs focus on wraparound care that is individualized to meet each family's needs. Previous research has illustrated significant disparities in outcomes of nonwraparound care on the basis of youths' race-ethnicity. This study aimed to fill a research gap by examining disparities in outcomes for families receiving wraparound care coordination within an SOC. This exploratory study examined racial-ethnic disparities in outcomes observed at intake, during service provision, and at 6-month follow-up among 1,138 youths and their caregivers who participated in wraparound care coordination as part of a statewide SOC between 2016 and 2020. Analyses of variance and regression analyses were executed to investigate whether receiving services and/or the youths' racial-ethnic identity predicted differences in behavioral health outcomes and characteristics of or satisfaction with care. Caregiver-reported outcomes were assessed with the Ohio Scales for Youth, the Child Trauma Screen, and the Caregiver Strain Questionnaire. Results revealed few racial-ethnic disparities in the characteristics and outcomes of care coordination among participants at intake or in family involvement in the wraparound process. Participants across groups reported similar and significant improvement in outcomes. However, the results indicated some disparities in satisfaction with care. Results revealed the positive impact of care coordination on the health and well-being of youths and caregivers across racial-ethnic groups.

Multiple Perspectives of Teams’ Experiences of a New Zealand Wraparound Process

Since it was first introduced in the 1980s, Wraparound has been defined as ‘a philosophy,’ ‘an approach,’ and ‘a service’ which is designed to work with youth and families with high and complex needs. Wraparound is most commonly understood as an intensive, individualised care planning process. It aims to achieve positive outcomes through a structured, creative, and individualised team planning process, which results in effective and more relevant plans for the youth and family. The purpose of this qualitative study was to explore the experiences of Wraparound facilitators, caregivers, youths, and team members to gain a multi‐perspective insight into the process. Sixteen families and Wraparound teams participated in the study which resulted in 56 semi‐structured interviews being conducted involving 16 Wraparound facilitators (some facilitators were interviewed more than once because they served multiple families who participated in the study), 16 caregivers, eight youth, and 16 team members (one person from the team, i.e., teacher, social worker, or mentor). Thematic analysis gave seven themes organised into three broad domains: (1) key elements of the Wraparound process including the Wraparound facilitator, Wraparound's philosophies and principles, and the supportive nature of the process; (2) the outcomes achieved throughout the process including family empowerment and hope, improved family dynamics and relationships as well as individual parent and youth change; and (3) the challenges and feedback respondents identified through the process, which included personal and systemic challenges, improved transition, and continuity of care, role clarity, and accessibility of the service. Overall, the findings from this study support Wraparound as an effective process for youth and their families, identify the importance of key aspects of the process, and suggest some improvements to increase the efficacy of and accessibility to the process.

Measuring Wraparound Fidelity to Make Quality Improvements

Wraparound care coordination has offered an individualized family approach to providing services to families in our county for the past decade. Instigated by our county mental health department interested in providing quality improvements to mental health services for families, we assessed the wraparound care coordination process through use of the Wraparound Fidelity Index (WFI), which measures adherence to established principles of wraparound. This article reports on findings from WFI data collected over three summers and reported back to the management team and family organization. Improvements were decided through consensus and included recommendations of parents and care coordinators. The goal of our study was to identify which activities and supports of wraparound were in need of improvement, enact quality improvements to address these areas and determine whether we were doing a better job over time.

Family Voice With Informed Choice: Coordinating Wraparound With Research-Based Treatment for Children and Adolescents

The wraparound process is a type of individualized, team-based care coordination that has become central to many state and system efforts to reform children's mental health service delivery for youths with the most complex needs and their families. Although the emerging wraparound research base is generally positive regarding placements and costs, effect sizes are smaller for clinical and functional outcomes. This article presents a review of literature on care coordination and wraparound models, with a focus on theory and research that indicates the need to better connect wraparound-enrolled children and adolescents to evidence-based treatment (EBT). The article goes on to describe how recently developed applications of EBT that are based on quality improvement and flexible application of “common elements” of research-based care may provide a more individualized approach that better aligns with the philosophy and procedures of the wraparound process. Finally, this article presents preliminary studies that show the feasibility and potential effectiveness of coordinating wraparound with the Managing and Adapting Practice system, and discusses intervention development and research options that are currently under way.

Developing a Community Care Team: Lessons Learned From the Community Connections Program, a Health Care Home–Community Care Team Partnership

This article describes the development of the Community Connections Program (CCP), a community care team, within a health care home (HCH), as a short-term, intensive, team-based service planning and coordination program for older adults with multiple chronic health conditions. Three proven approaches were combined to support patient's self-management, nurse care coordination, the Wraparound process, and use of community services. Particzpants'responses to the CCP demonstrated the success of the community care team in connecting patients and nurse care coordinators (NCCs) with community service providers, thus supplying primary care providers with important information regarding the development of a community care team to support patient-centered care within a HCH.

Youth with Serious Mental Health Disorders: Wraparound as a Promising Intervention in New Zealand

Youth with serious mental health disorders present with a complexity of challenges for the mental health system, schools, youth justice, care and protection, and their communities. Research shows their needs are best achieved by providing coordinated intensive, multidisciplinary, and individualised services. This article outlines the prevalence and characteristics of youth with serious mental health disorders. It also discusses community-based interventions used in New Zealand and their limitations. It introduces Wraparound, an intensive individualised coordination and care planning process as a promising practice for youth with serious mental health disorders and their families. Key principles and phases underpinning the Wraparound process are presented along with a case vignette to exemplify the process. Its theory of change, the challenges experienced in practice, and a brief overview of the evidence-base are also discussed.

Fit of Evidence-Based Treatment Components to Youths Served by Wraparound Process: A Relevance Mapping Analysis

This study investigated whether and which evidence-based treatment (EBT) components might generalize to youths served by the wraparound process. To examine these questions, the study used relevance mapping, an empirical methodology that compares youths in a given clinical population with participants in published randomized trials to determine who may be “coverable” by EBTs and which treatments may collectively be most applicable. In a large diverse clinical sample, youths receiving wraparound services (n = 828) were compared with youths receiving other services (n = 3,104) regarding (a) demographic and clinical profiles, (b) “coverability” by any EBTs, and (c) specific practices from those EBTs that most efficiently applied to each group. Participants in studies of EBTs matched the demographic and clinical characteristics of nearly as many youths receiving wraparound (58–59%) as those receiving non-wraparound services (61–64%). Moreover, the best-fitting solutions of relevant sets of practices were highly similar across groups. These results provide the first large-scale empirical characterization of fit between EBTs and youths receiving wraparound and suggest that these youths are well suited to benefit from clinical strategies commonly used in EBTs.

Enhancing Patient-Centered Care

Health care reform focuses on primary care and development of Health Care Homes to improve patient-centered chronic illness care. This pilot study evaluated a community care team intervention that linked chronically ill older patients, support persons, and nurse care coordinators from a Health Care Home with community resources using an adaptation of the Wraparound process. A pragmatic clinical trial design was used. Patient-centered chronic illness care; physical, mental, and social health; service use; and study feasibility were evaluated. Differences between groups were compared using two-sample t, Wilcoxon rank sum, chi-square, or Fisher's exact tests. At 3 months, the intervention group reported higher patient-centered chronic illness care (mean total Patient Assessment of Chronic Illness Care change scores were 0.39 for the intervention group and -0.11 for the control group, p = .03). Results indicate that the integrated community care team intervention is a promising strategy to support patient-centered chronic illness care.

Evaluating fidelity to the wraparound service model for youth: application of item response theory to the Wraparound Fidelity Index.

The wraparound process is a mechanism for multisystem planning and care coordination for youth with serious emotional and behavioral problems. Fidelity monitoring is critical to effective implementation of evidence-based practices in children's mental health, as it helps ensure that complex interventions like wraparound are implemented as intended. The 40-item Wraparound Fidelity Index, Version 4 (WFI-4; Bruns, Burchard, Suter, Leverentz-Brady, & Force, 2004) is the most frequently used measure of fidelity to the wraparound process, but analysis of its psychometric properties is insufficient. An item response theory approach, Rasch partial credit models for ordered polytomous data, was used on ratings from 1,234 facilitators, 1,006 caregivers, and 221 team members, focused on 1,478 youths (55% male). Results indicated the WFI-4 measured a unidimensional construct, with little evidence of item bias and good item and model fit. However, the item information curve was skewed, with most people endorsing high-fidelity responses, and several items had duplicative location estimates. A reduced 20-item measure is proposed. Internal reliability estimates for scores from this reduced measure were approximately equivalent to the longer measure. However, both versions would benefit from additional items located in the highest fidelity area of either version of the scale where scores by greater than half of our sample fall, but only 3 items are located.

The wraparound process for youth with severe emotional behavioural disorders

The number of youth with serious emotional disorders has increased tremendously; unfortunately, meeting the needs of such children has been a challenge. In an effort to deal with the challenging behaviour exhibited by children and youths, expensive out‐of‐home placements such as juvenile justice centres and clinical and psychiatric hospitalisation, have been used. Unfortunately, these approaches have not been effective in reducing the rate of challenging and violent behaviours. Therefore, researchers continue seeking evidence‐based and cost‐effective strategies to use when dealing with children and youths with severe emotional disorders. One of the approaches that have emerged out of this search is the systems of care model, which places emphasis on shifting placement of individuals with severe emotional disturbance from restrictive institutional settings to less restrictive settings. Central to the systems of care model is the wraparound process. The approach involves providing a set of coordinated individualised services and natural supports to the child and family in their natural environment. The purpose of this paper is to provide a literature synthesis on the wraparound process.

Research on the Wraparound Process: Intervention Components and Implementation Supports

In 1996, when the time since the advent of ‘‘systems of care’’ (Stroul and Friedman 1996) for youths with serious emotional and behavioral problems was still measured in terms of years and not decades, this journal provided the children’s services field with a landmark Special Issue focused on research on the wraparound process and individualized services for children with complex needs (Clark and Clarke 1996). The Special Issue aimed to provide the first comprehensive academic perspective on wraparound, which was at the time one of a variety of ‘‘innovative alternatives to highly restrictive, categorical services and costly institutional care’’ (p. 2), on which outcomes studies were only beginning to be published. The goals for the 1996 special issue were to: (a) provide a definition of the wraparound process and a rationale for its use, (b) illustrate potential applications of the approach, and (c) present results from studies that shed light on the potential for wraparound’s positive impact. As described by the Special Issue’s discussant (Rosenblatt 1996), the Special Issue also aimed to put this new strategy on a developmental pathway that would lead its specification and refinement to be guided by theory and research, rather than by ‘‘fad and fashion,’’ lest wraparound become yet another ‘‘program of great promise that fell by the wayside once [its] moment in the sun passed’’ (p. 114). Fifteen years later, we can report that far from falling by the wayside the wraparound process has become an organizing framework and prominent practice model through which community-based services for a broad range of populations with complex needs are delivered. As described by Bruns, Sather, Pullmann, and Stambaugh in this Special Section, it is estimated that the wraparound process is available via nearly 1,000 initiatives in nearly every one of the United States with the number of states taking implementation statewide increasing every year (Bruns et al. 2010). We also have observed that the field has continued to make progress in the areas discussed in the 1996 Special Issue. Wraparound’s principles, practice model, and organizational and system support conditions have undergone systematic examination over the past 10 years, in a way that intends to provide adequate specificity to permit replicability and quality assurance while maintaining the strategy’s ability to be adapted to local conditions and populations (Bruns et al. 2010; Walker and Bruns 2006; Walker et al. 2011). Nine controlled studies of wraparound are now in the peer reviewed literature (Bruns and Suter 2010), with a recently completed meta-analysis demonstrating significant positive effects and mean effect sizes ranging from 0.31 for mental health symptomotology to 0.44 for residential placement (Suter and Bruns 2009). Finally, examples of applications of wraparound continue to proliferate and gain national attention. The initiatives studied in the above reviews and meta-analysis span mental health, juvenile justice, and child welfare (Suter and Bruns 2009), and the wraparound process is now frequently referenced as a practice model that can facilitate integration of care for complex populations of all ages. Achieving E. J. Bruns (&) Division of Public Behavioral Health and Justice Policy, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA e-mail: ebruns@u.washington.edu

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 Community Supports for Wraparound Inventory: An Assessment of the Implementation Context for Wraparound

The wraparound process has emerged as perhaps the most frequently implemented comprehensive approach for planning and providing individualized, community-based care for children and adolescents with serious mental health conditions. Providing comprehensive care through the wraparound process necessarily requires a high level of collaboration across organization and agency boundaries. This need for significant inter-agency or “system-level” collaboration creates a complex implementation environment for wraparound. It is therefore not surprising that creating and sustaining a hospitable implementation environment has proven to be extremely challenging. For the people who are responsible for managing the inter-organizational collaboration, it is not easy to evaluate the adequacy of local system-level support for wraparound and to see exactly what kinds of supports are lacking or where system-development efforts should focus. Furthermore, as system-development strategies are put into practice, it can be difficult to assess whether or not meaningful progress is occurring. The Community Supports for Wraparound Inventory (CSWI) was developed to respond to the need for an assessment of the extent to which a community has developed system-level capacity to implement wraparound. This article reports on a study that evaluated the reliability and validity of the CSWI for use in communities implementing wraparound. Findings indicate that the CSWI shows promise as a reliable, valid and useful tool.

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.

Intervening in the Lives of Youth with Complex Behavioral Health Challenges and Their Families: The Role of the Wraparound Process

Wraparound is an individualized, team-based service planning and care coordination process intended to improve outcomes for youth with complex behavioral health challenges and their families. In recent years, several factors have led wraparound to become an increasingly visible component of service systems for youth, including its alignment with the youth and family movements, clear role within the systems of care and public health frameworks, and expansion of the research base. In this paper, we provide a review of the place of the wraparound process in behavioral health, including a discussion of the opportunities it presents to the field, needs for further development and research, and recommendations for federal actions that have the potential to improve the model's positive contribution to child and family well-being.

The Status of States' Policies to Support Evidence-Based Practices in Children's Mental Health

This study examined the efforts of states' mental health authorities to promote the use of evidence-based practices through policy. Data were drawn from three components of a national study, including a survey of state children's mental health directors (N=53), which was developed using a three-step process that involved stakeholders. Data from the directors' survey revealed that over 90% of states are implementing strategies to support the use of evidence-based practices. The scope of these efforts varies, with 36% reporting statewide reach. Further, states' strategies for implementing evidence-based practices are often not accompanied by comparable efforts to enhance information systems, even though enhancing such systems can bolster opportunities for successful implementation. Variability in the adoption of evidence-based practices, poor attention to information systems, and inconsistent fiscal policies threaten states' efforts to improve the quality of children's mental health services.

APA Seeks Ideas to Sever Mental Illness, Delinquency Link

APA Seeks Ideas to Sever Mental Illness, Delinquency Link

Effectiveness of the Wraparound Process for Children with Emotional and Behavioral Disorders: A Meta-Analysis

Wraparound is a team-based service planning and coordination process intended to improve outcomes for children and youth with serious emotional and behavioral disorders and support them in their homes, schools, and communities. Given the substantial resources devoted to implementing wraparound, a meta-analysis of outcome studies was conducted to better understand current empirical support for this process. A literature search identified seven studies between 1986 and 2008 that documented the effects of youth receiving wraparound compared to control groups. Mean treatment effects across outcome domains ranged from medium for youth living situation (0.44) to small for mental health outcomes (0.31), overall youth functioning (0.25), school functioning (0.27), and juvenile justice-related outcomes (0.21). The overall mean effect size across studies was 0.33. Interpretation of results was complicated by the lack of consistent documentation of implementation fidelity across studies and conditions, variations in target population and intended outcomes, and methodological concerns. The authors conclude that, though the published wraparound research base is expanding and findings are largely positive, it continues to be in a preliminary state of development. However, there are insufficient data to support calls for wraparound's acceptance or dismissal based on the strength of existing studies.