TEAMS R34 #1 After-Action Reviews in Child Welfare Services

Study Overview
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Brief Summary
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This project proposes to improve successful mental health service linkage in Child Welfare Services (CWS) by adapting and testing the After Action Review (AAR) team effectiveness intervention to augment the Child Family Team (CFT) services intervention. Despite being both required and a collaborative approach to service planning, CFT meetings are implemented with questionable fidelity and consistency, rarely including children and families as intended. By inclusion of child and family voice, the AAR-enhanced CFT should lead to increased fidelity to the CFT intervention and greater levels of parental satisfaction with the service and shared decision-making, thus resulting in enhanced follow-through with Action Plans and linkage to mental health care for children.

Detailed Description
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The proposed project will address the following aims: Aim 1. Conduct a qualitative needs assessment targeting the ongoing implementation of the CFT services intervention in a large, publicly funded, CWS. A qualitative inquiry consisting of interviews and focus groups with key stakeholders will result in the preparation of an action plan to address identified gaps between the current and desired CFT services intervention outcomes. Aim 2. Adapt and tailor the AAR implementation strategy to address the CFT services intervention needs. Aim 3. Assess mechanisms of the AAR team effectiveness intervention for CFT implementation.

Official Title
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TEAMS R34 #1 After-Action Reviews in Child Welfare Services

Conditions
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Mental Health Issue, Children, Adult

Intervention / Treatment
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* Behavioral: After-Action Review


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Inclusion Criteria for CWS leaders and/or caseworkers (For leaders) Employed as one of several CWS leadership positions: CWS Director, CWS Deputy Director, CWS Regional Manager; (For caseworkers) Employed as a caseworker in one of the two participating regions for the proposed study. Plans to remain employed for at least six months beyond study initiation Speaks English or Spanish Inclusion Criteria for formal and informal CFT members Member of CFT with one of the participating CWS caseworkers. CFT members can include mental health services provider, Court Appointed Special Advocate (CASA), educational representative, and other supports Speaks English or Spanish Inclusion Criteria for parents/caregivers with active CWS cases Parent/caregiver of child aged 6-17 with an open CWS case Initial CFT meeting for open CWS case has not yet been held (Aim 3) Speaks English or Spanish Inclusion Criteria for children with active CWS cases (for mental health service linkage data extraction only*) Child aged 6-17 with an open CWS case Mental health services need/s (identified by the CWS caseworker via CANS screening in advance of the initial CFT meeting, during which consensus is reached regarding the Action Plan and service referral) Exclusion Criteria: Individuals who do not meet inclusion criteria are not eligible to participate in this study.

Ages Eligible for Study
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Minimum Age: 6 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Child Family Team (CFT) as Usual<br>The CFT is a family meeting model that is an existing mechanism being implemented systemwide in San Diego County Child Welfare Services (CWS). Each child or youth is required to have a CFT meeting within sixty days of entering the CWS to identify areas of behavioral, emotional, or social needs, and to complete an initial case Action Plan. | |
| Experimental: Child Family Team (CFT) with After Action Review (AAR)<br>CFT is being augmented with the after-action review. | Behavioral: After-Action Review<br>* After-action reviews, or debriefs, are a relatively simple, inexpensive, and quick, tool to improve learning, performance, and the effectiveness of teams and individuals. After-action reviews are active self-learning processes wherein participants reflect on specific performance episode to actively engage in self-discovery and improve learning in a non-punitive/non-judgmental manner to result in enhanced performance. This proposal aims to apply the team effectiveness intervention of the after-action review (AAR) to the services intervention of the Child and Family Team (CFT) meetings currently used in the CWS.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Working Alliance Inventory Short Form (WAI-SR) | The WAI-SR is a 12-item version of the Horvath and Greenberg's (1989) Working Alliance Inventory. Each item is responded to using a 7-point likert-type scale. Each of the subscales will measure proposed mechanisms, while the overall scale will measure proposed outcomes. The 4-item Goal subscale will be used to determine team member agreement on goals for CWS child/family case treatment plan (goal specification). The 4-item Task subscale will be used to determine team member agreement on how to achieve goals for CWS child/family case treatment plan (strategy formulation). The 4-item Bond subscale will be used to determine the personal bond between CFT team members (trust). The overall scale score assesses the collaborative relationship between relevant parties; consensus and willingness by all to engage in and do the work that leads to improvement (CFT Fidelity). Each participant will complete the WAI-SR immediately following their completion of the intervention (<1 hour) | through study completion,  9 months | 
| Collaboration & Satisfaction About Care Decisions (CSACD) | The 6-item collaboration subscale assesses collaboration, shared responsibilities for planning, open communication, and coordination. The 3-item satisfaction subscale assesses satisfaction with the decision-making process, and satisfaction with the decision itself. Although originally developed about care decisions for intensive care patients, it has since been used to measure collaboration and satisfaction with treatment planning plans associated with after-action reviews. Each participant will complete the CSACD immediately following their completion of the intervention (<1 hour). Participants respond on a 7-point likert-type scale ranging from 1=strongly disagree to 7=strongly agree. Subscale scores are computed by calculating the average item response for items representing collaboration, and items representing satisfaction, respectively. | through study completion,  9 months | 
| San Diego (SD) County Behavioral Health Administrative Data | During the CFT meetings, behavioral health needs initially screened via the CANS assessment will likely be confirmed for many child/families with open CWS cases. For children/families with behavioral health treatment plans, SD County Behavioral Health Administrative Data will be assessed to determine successful service linkage. | through study completion,  9 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Acceptability, Feasibility, and Appropriateness of Intervention Measure | This 9-item measure will be administered to CFT+AAR participants immediately following completion of the CFT+AAR intervention (<1 hour) to assess the extent to which the After-Action Review is appealing, liked, and welcomed in their setting (acceptability); fitting, suitable, and applicable in their setting (appropriateness); possible and doable in their setting (feasible). Each of the 9 items is rated using the following response options: 1=completely disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, and 5=completely agree. Three subscales can be created by averaging responses for items representing acceptability, appropriateness, and feasibility, respectively. | through study completion,  9 months | 
| Participant demographics professional characteristics | Participant age, gender, race, ethnicity, marital status, education level, primary language, and working status/profession will be collected of all participants immediately following completion of the intervention (<1 hour). | through study completion,  9 months | 
| Card-Sorting Task | Card sorting elicits individual mental models to understand how participants structure their knowledge. In open card sorts participants are provided with a set of key concepts and asked to sort them into categories. Each participant then creates a label for each category. In closed card sorts, participants are similarly given a set of key concepts, but participants are given pre-defined categories that each concept must be sorted into. Within team environments, card sorting can be used to examine the degree to which team members are thinking about key concepts in a similar manner (e.g., team mental models) by comparing the categories and sorted content across members. For this proposal, each participant will complete the card sorting task immediately following completion of the intervention (<1 hour). In doing so, the concepts contained in the card sort will be representative of specific CFT roles, task responsibilities, and goals. | through study completion,  9 months | 
| McAllister Affect-Based Trust | This 5-item scale assesses perceptions of affect-based trust amongst CFT members. Items center on individual's perceptions that team members can share ideas freely, that team members listen to one another, that team members care for one another, and that team members are invested in working well with one another. Each participant will complete the WAI-SR immediately following their completion of the intervention (<1 hour). Participants respond on a scale ranging from 1=strongly disagree to 7=strongly agree, and scale scores are computed by calculating the average item response. | through study completion,  9 months | 
| Psychological Safety | Edmondson's 7-item Psychological Safety Climate Measure evaluates perceptions of the work environment (in this case, the CFT meeting) as being one wherein policies and procedures foster a safe and comfortable space for interpersonal risk. Each participant will complete the Psychological Safety Climate Measure immediately following their completion of the intervention (<1 hour). Participants respond on a scale ranging from 0=doesn't apply at all to 4=entirely applies, and overall scale scores are computed by calculating the average item response. | through study completion,  9 months | 
| Parent Participation Engagement Measure (PPEM) | This 5-item measure originally developed for culturally diverse families served in children's outpatient mental health, was adapted for CWS home visitation services, and assesses active parent participation, engagement, and voice in treatment services. Each participant will complete the PPEM immediately following their completion of the intervention (<1 hour). Participants respond on a 5-point likert-type scale ranging from 1=not at all to 5=very much. Scale scores are computed by calculating the average item response. | through study completion,  9 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Child Welfare Services, Team Effectiveness Research, Shared Decision Making