Multidimensional Treatment Foster Care

Description The Multidimensional Treatment Foster Care (MTFC) Program was developed in the early 1980s as an alternative to institutional, residential, and group care placements for boys with severe and chronic criminal behavior. Subsequently, the MTFC model has been adapted for and tested with children and adolescents with severe emotional and behavioral disorders leaving a state mental hospital, girls referred from juvenile justice for severe delinquency, and with preschool children in regular state-supported foster care. Randomized trials have focused on a variety of outcomes including prevention of substance use, pregnancy, and placement disruption, positive attachment to caregivers, time spent in the community (versus in institutions), and positive academic outcomes. Additionally there is a large scale randomized trial currently underway in the States of California and Ohio that examines factors that predict successful implementation of MTFC and barriers to implementation in community agencies. Program Objectives There are two major aims of MTFC; to create opportunities for youth to successfully live in a family rather than group or institutional settings, and to simultaneously coach parents (or other long-term family resource) to provide effective parenting in order to support sustainable success over time. MTFC targets provision of five key areas in treatment and aftercare: (1) a consistent, reinforcing environment with mentoring and encouragement, (2) daily structure with clear expectations and specific consequences, (3) a high level of youth supervision (4) limited access to deviant peer associations concurrent to frequent access to prosocial peers along with support and assistance for developing peer relationships, and (5) an environment that supports daily school attendance and homework completion. Program Strategies Placements in MTFC are typically 6-9 months in length and rely on intensive, wellcoordinated, multi-method interventions conducted in the MTFC foster home, with the youths aftercare family, and with the youth through individual therapy, skills coaching, and academic support. A program lead (with a caseload of 10) oversees and coordinates the interventions across settings (e.g., home, school, community). Involvement of the family (or other long-term home) is emphasized from the outset of treatment in an effort to maximize the family work and prepare parents for youth returning home. Progress is tracked through daily phone calls with MTFC foster parents where data is collected on youth behavior and levels of foster parent stress. Youth in MTFC Referrals are received from juvenile courts, probation officers, mental health and child welfare workers. Youth referred to MTFC for Adolescents (MTFC-A) are between the ages of 12 and 17 and are in need of an out of home placement due to serious behavioral and/or emotional problems. Referred youth may have been involved in serious criminal offending behavior and may have complex co-morbid mental health disorders. Most referred youth have been involved in numerous treatment efforts prior to their referral to MTFC-A, and most have experienced at least one, if not

1163 Olive Street Eugene, Oregon 97401 Phone: (541) 343-2388 Fax: (541) 343-2764 Web: MTFC.com

multiple, failed placements. Referrals to MTFC-A programs are most appropriate after in-home family preservation programs have been tried or when youth are returning from highly restrictive institutional or group care placements. Families of MTFC-A youth participate in the family therapy component of treatment and should be engaged in services immediately upon placement in the program. Referral information should identify the family to which the youth will reside long-term after MTFC-A or identify independent living as the living situation upon discharge. Youth exhibiting acutely suicidal, homicidal or psychotic behavior should l not be placed in the MTFC-A program. Because of the intensive nature of the MTFC program, youth are expected to participate exclusively in MTFC-A as the sole and comprehensive treatment service. In addition, youth in need of exclusive treatment for sex offenses or substance abuse are not appropriate for MTFC-A. Staffing MTFC team leaders, (who are called Program Supervisors), are trained in the social learning treatment model and are responsible for coordinating all aspects of the treatment program. They serve as consultants to the foster parents, provide support and supervision in the form of weekly meetings and daily telephone contact, and are available for support, consultation, and backup 24 hours a day. Foster parents are screened, selected, and trained before an MTFC youth is placed in their home and are supervised and supported throughout the placement via daily telephone calls, weekly foster parent groups conducted by the Program Supervisor, and quick access to the Program Supervisor after hours. The team also consists of a family therapist, an individual therapist, skills coaches, and a foster parent Recruiter/Trainer/Parent Daily Report Caller. All team members are employed by the program and are supervised by the Program Supervisor. Special Characteristics Involvement of the biological family or other long-term family is emphasized throughout treatment. Families are coached and supported in learning specific parenting approaches that are practiced during contact with the youth. Families have access to the program 24/7 to assist in the moment during visits and provide them with access to information. Comments on Implementation/Replication TFC Consultants, Inc. (http://www.mtfc.com) was founded in 2002 and is dedicated to the implementation of model-adherent MTFC programs. TFC Consultants provides consultation, training, and technical assistance to new and existing MTFC programs and helps service providers, policy makers and community leaders resolve issues related to the implementation of evidence-based practices. Through TFC Consultants, MTFC is currently implemented in many states throughout the U.S., as well as in Sweden, Norway, Denmark, The Netherlands, United Kingdom, Ireland and New Zealand (a complete list of sites is available at www.mtfc.com). Research Conclusions MTFC-A has shown to be an effective and viable method of preventing the placement of youth in institutional or residential settings. Studies have found that placement in MTFC can prevent escalation of delinquency and youth violence, pregnancy in girls and to increase positive academic engagement. Additionally, MTFC has been found to be more economical and more effective than placement in group care in decreasing offense and incarceration rates post treatment. Overall, MTFC has been shown to be effective in the treatment of boys with severe delinquency and conduct disorders (Chamberlain, & Reid, 1998), in the treatment of children and adolescents leaving a state mental hospital (Chamberlain & Reid, 1991), in the prevention of placement disruptions in regular state supported foster care (Chamberlain, Moreland & Reid, 1996), and in the treatment of girls with chronic problems with delinquency (Leve & Chamberlain, in press). In addition, specific treatment components (i.e.,

close supervision, fair and consistent limit setting, decreased association with delinquent peers, positive adult-youth relationship) have been shown to be factors that account for the treatment effect of MTFC placements (Eddy & Chamberlain, 2000). Participation in MTFC-P has been shown to prevent placement disruptions, increase attachment between children and foster parents, and to lead to increases in brain stress regulatory systems. Resources The websites listed below contain information about MTFC and its evidence base. http://about.preventiondss.org/html/documents/DoE/exemplary/OSLC.htm http://www.ncjrs.org/pdffiles1/ojjdp/173421.pdf http://captus.samhsa.gov//western/resources/prevmat/bppbookSx.pdf http://www.nexuskids.org/National%20Programs/MTFC.htm http://www.strengtheningfamilies.org/html/model_programs_1997/mfp_pg4.html www.evidencebasedprograms.org In addition, please visit our website at www.mtfc.com. We believe that the best source of detailed information about the various components of the model is a book by program founder Patricia Chamberlain, titled Family Connections. The book contains case examples as well. It is available at Northwest Media in Eugene for $29.95 plus S/H. In the alternative, we can send you the book as well.

Implementation Services & Fees Implementation services are provided by TFC Consultants, Inc. Our guidance and support begins with an evaluation of the feasibility of MTFC at your organization. If successful, a program development phase then begins followed by the first year services. Feasibility & Readiness Successful implementation of MTFC requires a thorough review of the circumstances in your organization and community, upfront training of clinical staff and foster parents, a prolonged period of consultation services and technical assistance, and a plan for perpetual model adherence monitoring. In order to determine if MTFC is a good match for your organization and community, a feasibility check is conducted. This is done by telephone or e-mail, and includes discussion of the topics listed in the MTFC Feasibility Review. There is no charge for feasibility review activities. If the feasibility indicates that the right circumstances exist for a successful MTFC program, TFC Consultants will work with you to prepare for an implementation and ensure that obstacles to a successful program are addressed prior to the start of the implementation activities. This next program development phase is the MTFC Readiness process. In this phase areas for further planning and coordination are identified and a timeline for your implementation is developed. The readiness topics will include a staffing, establishment of the placement criteria, referral mechanisms, the understanding and support of relevant systems, agencies, and funders in your community, and planning for and supporting initial foster parent recruitment. To assist you in the financial planning for your MTFC program, we have created and can provide you with the MTFC Cost Calculator. It is a customizable Excel tool and is reviewed with you in line by line during the initial readiness process to establish that adequate funding is available for the program. The readiness contacts are conducted via a series of conference calls, usually lasting 1 - 2 hours each. Each call will address one or several readiness topics depending on the pace of program development and the success of problem solving potential barriers. Call summaries will be provided in writing and sent to you via e-mail. The entire readiness process typically takes several months. Near the end, a Readiness Questionnaire is completed and returned to us for evaluation. A final determination of MTFC viability is made upon review and discussion readiness information provided in the questionnaire. The cost of the readiness assessment is $1,500, payable prior to the first readiness telephone conference. First Year Services During the first year of implementation, the following services are provided to initiate and support a developing program. These are provided for one team which serves approximately 10 youth at any one time.

Recruitment Consultation Consultation and guidance on the recruitment of MTFC specific foster parents Stakeholders Presentation and Implementation Planning Meeting (to be held at your agency) o Stakeholders Presentation - an overview and of the model is presented to stakeholders, including administrators, program staff, any MTFC foster parents that may have been identified, as well as representatives from relevant outside entities, such as schools, mental health, child welfare and

foster care certification agency. Discussion of questions, concerns and barriers. o Planning Meeting a clear and specific implementation plan, including timelines, is finalized for staffing, training, foster parent licensing and placements. Clinical training (Eugene, OR) The duration of training is role dependent. Program Supervisors attend 5 days, therapists attend 4 days, and the Recruiter/Trainer/PDR caller attends 3 days. Please see below for an overview of the MTFC clinical team. In addition to the clinical staff, an agency manager or administrator is also recommended to attend. You may also choose to send a representative of a funding or referring agency as well. Foster parent training (held at your agency) TFC Consultants conducts your first foster parent training. This is a two day training for the first group of MTFC foster parents. Subsequent foster parent trainings are conducted by your MTFC Recruiter/Trainer. WebPDR training Training in the web-based behavior data tracking system is conducted for the MTFC PDR caller, Program Supervisor (see staffing information below) and the identified backup PDR caller. Use of the WebPDR system Use of the web-based behavior information system, which contains daily behavioral information on each MTFC youth in placement, for up to 12 active placements at any one time. Remote technical assistance is included. Weekly Consultation A consultant is assigned to your MTFC program and provides weekly telephone consultation to the MTFC Program Supervisor. The consultation includes review of each MTFC youth, their treatment plan and progress, staff supervision and role adherence, program functioning and systems issues and overall implementation. In addition, the consultant will view video recordings of program meetings from the previous week and provide feedback within each call. Consultation begins approximately two weeks before the first placement is made and prior to final matching and placement decisions. Site visits The consultant will come to your program for a maximum of 6 days, divided into 3 site visits. Visits can include attendance to the foster parent and clinical meeting, include booster training (not to replace clinical training in OR), problem-solving, and in the moment consultation and support. The consultant will work with the implementation site to create a visit agenda and determine the timing of site visits however they are generally provided every three months after consultation calls have begun. Programs reviews Three periodic reports are provided to the program director or administrator that includes information regarding implementation progress, program staff performance, model adherence and other relevant issues. Program assessment At the end of the first year, the program is assessed in a number of domains relevant to program certification criteria. Areas that do not yet meet the fidelity criteria will be identified and follow-up assistance will be provided in these areas.

The fee for the services provided during the initial year of implementation is $46,500. Additional costs include travel and lodging expenses for your organizations MTFC staff to attend clinical training in Eugene, OR and for travel and lodging of TFC Consultants staff for the stakeholders meeting, foster parent training and site visits. Implementation Services Beyond Year One The implementation services needed following the initial year of implementation will depend on the results of the Program Assessment mentioned above. For each area that does not yet meet program certification standards, specific consultation and

assistance will be provided for a period of four months, followed by another program assessment. The assessment will again determine further consultation services. This process is repeated until the program meets all certification criteria. The program will then apply for Program Certification with the Center for Research to Practice, a non-profit research organization. The certification packet is attached but can also be found on our website. Ongoing model adherence and outcome measurement are crucial to sustaining a successful program over time. The certification mechanism enables programs to evaluate practices and procedures and maintain a high degree of model fidelity after technical assistance and consultation ends. Please note that program certification can only be applied for after the program has been in operation for at least one year. Initial program certification is valid for a period of two years, at which point recertification should be applied for. Re-certification is valid for a period of three years. At nine-month intervals following initial certification and at ten-month intervals following re-certification, Program Assessments will be conducted by TFC Consultants to determine if adherence and outcome standards continue to be met. Assistance will be provided in the specific areas of deficiency. The cost of the consultation and technical assistance services rendered after the first year are difficult to predict, as the type and quantity of services are determined by the outcome of the Program Assessment. Generally, implementation costs in the second program year are less than half of the cost associated with the first year. Subsequent years should require decreasing resources associated with ongoing model adherence. Please refer to the attached Fee Schedule. WebPDR (Parent Daily Report) WebPDR services will be needed as a perpetual requirement. The annual cost, including remote technical assistance, is $2,720 for each team (up to 12 active placements at any one time). For the first year, this fee is included in the cost of the comprehensive first-year services referred to above. Service agreements Contractual arrangements for training, consultation and technical assistance include: First-year implementation services as listed above; Program assessments at 4-month intervals after the first year, until program certification is obtained; Ongoing consultation and assistance as indicated by the program assessments; Program assessments at 9 or 10-months intervals upon obtaining program certification; Consultation and assistance as indicated by the program assessments; Ongoing WebPDR services beyond the first year; Commitment to have new/replacement staff (except skills trainers) trained by TFC Consultants in Eugene prior to assignment to an MTFC team. Contracts do not have an end date and can be terminated by either party at any time, subject to a 30day notice provision. Multidimensional Treatment Foster Care and MTFC are registered service marks of OSLC Community Programs, Inc. Authorization to use these terms in the Agencys program name or program description is granted only to programs receiving implementation services from TFC Consultants or programs that have obtained program certification from the Center for Research to Practice (unless expired).

MTFC Staffing Staffing for the MTFC model is an important factor in the successful operation of the program. One program, which serves approximately ten youth at a time, requires the staffing pattern listed below.

Program Supervisor full time Foster Parent Recruiter/Trainer/PDR Caller to full time Child therapist time Family Therapist time Skills Coaches hourly Foster Family Consulting Psychiatrist

The program supervisor supervises the treatment team and is pivotal in the coordination of all activities. He or she organizes the placement, acts as liaison between the program and outside agencies, conducts an intake session with the youth, matches the youth with the foster parents, organizes and supervises contacts with schools and other organizations with which the youth may be involved, determines treatment plans for each youth in consultation with other treatment team members, conducts weekly clinical meetings and foster parent meetings, and is generally responsible for each placement. In addition to a Masters-level education in a clinical field and considerable relevant experience in behavior management approaches, this person should possess supervisory skills, considerable organizational abilities, and a thorough understanding of and enthusiastic attitude toward the treatment model. The program supervisor must be available to the foster parents and treatment team members 24 hrs/day, 7 days/week. The duties of recruiting foster homes, conducing the MTFC foster parent training, and conducting daily PDR calls are typically combined into one position. This important position should be filled by someone with a thorough understanding of the treatment model and experience in foster parent activities. The specific education level for this position is less important than their ability to be engaging, self-motivating and work well in a team. At the model site in Eugene, this position is often filled by an experienced (ex-) foster parent. The family therapist provides clinical services to the biological families (or other identified long-term placement resource) of the treatment youth. The family therapist conducts sessions weekly and attends the weekly clinical meeting. A masters-level education in a clinical field is recommended. The youth therapist serves as therapist to program youths in weekly sessions. Sessions typically occur in the community and provide a high level of support and guidance for youth. The child therapist also attends the weekly clinical meeting. A masters-level education in a clinical field is recommended. Mileage reimbursements and reimbursements for modest activities, food and beverage expenses are typically associated with this component of treatment as sessions take place in the community. The family therapist and child therapist services cannot be provided by the same person. Skills coaches typically hired in an hourly position. This position meets with youth weekly after school hours and provides opportunities for youth to practice new skills. Sessions are conducted in the context of recreational activities and include a high level of positive reinforcement and encouragement to youth. Sessions are typically 2 hours in length. For one MTFC program (10 placements), 20-25 hours of skill coaching a week are needed. Bachelors level education in a relevant field is

recommended. Since skills coaching activities take place in the community, mileage reimbursements and reimbursements for modest activities, food and beverage expenses are typically associated with this component of treatment. One MTFC foster home is needed for each youth as only one youth is placed in a home at any given time. Foster parents are front-line treatment agents in the MTFC model, and are required to attend weekly foster parent meetings in addition to the initial MTFC foster parent training. Ongoing training, participation in treatment plan adjustment and exchange of ideas and strategies are the purposes of the weekly meetings. Foster parents in this model are usually paid more than those in conventional foster care settings. It is important that MTFC foster parents have access to program staff, especially the program supervisor, 24 hours/day, 7 days/week. Foster parents provide daily information on the behavior of the child in their care by telephone. A relationship with a consulting psychiatrist is also needed to adequately serve youth in the program who need medication prescribed and managed. It is preferable to have all program youth in need of psychiatric services seen by the same psychiatrist.

MTFC Implementation Timeline

1. Information TFC Consultants sends model and implementation 2.

information. Review of the information by the client organization typically takes several weeks. Feasibility Review Completed by agency and reviewed by TFC Consultants. Based on the Feasibility Check, the client organization and TFC Consultants will assess the viability of implementation at the agency. Determining feasibility typically takes two weeks.

After feasibility is established, the Readiness process begins. The fee for the Readiness step is $1,500.

1. Readiness Preparation Calls Implementation site and TFC Consultants

review the factors and circumstances relevant to program implementation and operation during a series of telephone calls that typically last one to two hours each. Preparations for start-up, including the recruitment and licensing of and initial group of foster parents, takes place during this stage. The readiness process, including the resolution of issues identified during the process, tends to take at least two months, and often much longer if the recruitment and licensing of the initial MTFC foster homes is very time consuming. Once readiness is determined, Implementation Services commence.

1. Contract is completed and signed. The numbered activities listed below are
provided during the first year of the contract.

2. Stakeholders & Site Planning Meeting Stakeholders presentation (~ 3. 4.

5. 6. 7. 8. 9. 10. 11.

3hrs) and Planning meeting (~2-3 hrs) is held during a one day site visit to the implementation agency. Clinical Training Your MTFC clinical staff attend clinical training held in Eugene, OR. Foster Parent training for the first group of foster parents is held at the implementation site agency and is facilitated by an MTFC Foster Parent Trainer from TFC Consultants. This occurs within 30 days of the Clinical Training. Web PDR training facilitated by a Web PDR trainer from TFC Consultants. Consultation calls - occur weekly between assigned TFC Site Consultant and the implementation Program Supervisor. The first call usually occurs 1-2 weeks prior to the first MTFC placement. First placement is made. Video review of your sites weekly foster parent and clinical meetings. Video should be available to your consultant for review prior to each consultation call. Site visits typical contracts include 6 days (up to 3 visits) of on-site consultation by the site consultant to provide technical assistance and program evaluation. Implementation reviews are sent to implementation site management for feedback in progress of implementation and model adherence. Reviews are completed approximately every 4 months after the initial program startup. Program Assessment at the end of the first year, an assessment will indicate domains in which consultation services are still indicated.

Implementation services and remedial services to address model adherence issues beyond the first year of the contract will be provided as indicated by periodic Program Assessments.

MTFC FEE SCHEDULE (as of OCTOBER 2009)

Service Description Readiness Process First-year implementation services Full program assessment * Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Program assessment domain Remedial Remedial Remedial Remedial Remedial Remedial Remedial Remedial Remedial Remedial Remedial Remedial Remedial Remedial Remedial Remedial services services services services services services services services services services services services services services services services domain domain domain domain domain domain domain domain domain domain domain domain domain domain domain domain $ $ $ $ $ $ $ $ $ $ MTFC-A 1,500 46,500 1,840 240 240 560 240 240 160 160 $ $ $ $ $ $ $ $ $ $ MTFC-C 1,500 45,550 1,840 240 240 560 $ 240 $ 240 $ 160 $ 160 $ $ $ $ $2,400 $3,000 $2,160 $6,000 6,000 $320 $320 $2,400 $3,000 $2,160 $3,000 $6,000 $2,160 $6,000 $1,500 $320 $6,000 $320 $6,000 $6,000 $320 $320 240 240 160 160 $2,400 NC 240 320 560 240 $ $ $ $ MTFC-P 1,500 49,750 2,080 240 NC

1 - Program Completion and Outcomes 2 Therapy Components 2 - Placement Stability 3 - Behavioral Components 3 - Therapy Components 4 Foster Parent Meetings 4 - Behavioral Components 5 Clinical Team Meetings 5 - Coordination of Services 6 Program Staff 6 - Foster Parent Meetings 7 - Training 7 - Clinical Team Meetings 8 - Therapeutic Playgroup 9 - Program Staff 10 - Training

1 Program Completion 2 Therapy Components 2 - Placement Stability 3 Behavioral Components 3 - Therapy Components 4 Foster Parent Meetings 4 - Behavioral Components 5 Clinical Team Meetings *** 5 - Coordination of Services 6 Program Staff 6 - Foster Parent Meetings 7 - Training 7 - Clinical Team Meetings *** 8 - Therapeutic Playgroup **** 9 - Program Staff 10 - Training

WebPDR access and use, per account (up to 12 active placements at any one time, includes remote technical support) Two-day consultant site visit***** Clinical Training in OR for replacement staff - while receiving first-year implementation services that includes initial clinical training * All clinical staff other than program supervisors - 4 days ** * Program supervisors - 5 days ** * Foster parent recruiters/trainers/PDR callers - 3 days * Therapists - 4 days * Program supervisors - 5 days - while not receiving such services, or if not replacement staff * All clinical staff other than program supervisors - 4 days ** * Program supervisors - 5 days ** * Foster parent recruiters/trainers/PDR callers - 3 days * Therapists - 4 days * Program supervisors - 5 days Program Certification application (processed by the Center for Research to Practice in Eugene, OR)

$ $

2,720 2,640

$ $

2,720 2,640

$ $

2,720 2,640

$200 p.p. $400 p.p. $ $ $ 175 235 410 $750 p.p. $1,000 p.p. $ $ $ 660 800 1,100

$200 p.p. $400 p.p.

$750 p.p $1,000 p.p.

2,050

2,050

2,850

*The full program assessment at the end of year 1 is included in the fee for First-year implementation services **Fees for training fewer than 5 persons at once may be adjusted ***If remedial services are also being provided for domain 4 (A and C) or domain 6 (P), there is no additional charge for consultation regarding this domain ****If remedial services are also being provided for domain 6 or domain 7, the fee for services regarding this domain is reduced to $2,000 *****The fee for overseas site visits is $3,080