HOMEBUILDERS Provider Packet Report Template.xlsx

Attestation & Signature Page

Dear Provider, This Provider Packet collects information that is required as part of your Agreement with OCFS. Please complete all shaded gray areas of this form before submitting. You will also complete each tab with the requested information and submit any other required material listed below in the supplemental information area. A list of due dates has been provided below. This information must be reported no later than 30 days from the end of each quarter.

Once complete, you will submit by email to the Department Program Manager listed in your Agreement along with the following: OCFS-PMR.DHHS@maine.gov. We thank you for your efforts in providing this information to ensure compliance with your OCFS contract.

Performance Measure Report

Quarterly Narrative Report

QUARTERLY NARRATIVE REPORT

Provider will provide quarterly narrative of Deliverables

Staffing & Training Report

DISTRICTS: DEPARTMENT APPROVED

ORGANIZATIONAL CHART - IMPLEMENTATION PLAN - STAFFING PLAN

(Inserted upon approval)

Federal Required Report

List out any/all reasons for rejections.

Supporting Documentation

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Microsoft_Word_97_-_2003_Document2.doc HOMEBUILDERS® Referral Information Summary

Does this family meet the Homebuilders eligibility criteria:

For Placement Prevention:

For Reunifications:

If Homebuilders is not available, one of the following will occur:

· Child(ren) will be placed in protective custody;

· Court petition will be filed requesting placement;

· Voluntary placement agreement will be initiated;

Less intensive services have been exhausted or are not appropriate.

Maintaining the child in the home is not a temporary plan. The child is not on a waiting list or pending entry into group care, psychiatric care, or a juvenile justice institution.

The caregiver has been informed of the risk of placement.

The caregiver(s) will be available for intake within 24 hours of referral.

The referent has described the intensity of Homebuilders to the family (40 hours of direct service over 4 to 6 weeks), and

The child is in placement and will return home within 7 days of the start of services.

It is an unusually complex situation (e.g. caregiver or child ambivalence, disrupted attachment, unresolved risk factors, legal issues, caregiver lacks understanding of child treatment needs, etc.).

The referent believes less intensive reunification services will not suffice to address the reunification concerns.

The referent has confirmed the caregiver(s) will be available for an intake session within 24 hours of referral.

The referent has described the intensity of Homebuilders to the family (40 hours of direct service over 4 to 6 weeks), and at least one caregiver in the home is available to participate

Referral Information

Family Name:

Referring Agency Case #:

Home Phone:

Address:

City / Zip:

Work/Cell Phone:

Additional directions / pets / other notes:

Good times to call / reach family:

Message Phone:

Assigned Practitioner:

Referral Date:

Referral Time:

Referent Name:

Referent Phone:

Referent Email Address:

Referring Office:

Emergency Phone:

Fax:

FRS

Adoption

FVS

CPS

Indian Child Welfare

CFWS

Other: FAR

Referent Supervisor:

Referent Supervisor Phone:

Referent Supervisor Email Address:

Family Members

Name

Role in Family

DOB

Gender

Race / Ethnicity

Tribal Affiliation

Mobile Phone

Identified Youth

Primary Caregiver

Other:

Race:

Hispanic: Yes No

Other Ethnicity:

Identified Youth

Race:

Identified Youth

Race:

Identified Youth

Race:

Identified Youth

Race:

Family Information

Referring Agency ID#:

Family aware and willing to participate:

Yes If not, who: No

Anyone restricted from contact?

Yes If yes, who: No

Potential for Violence within Family:

Unk.

None Low Mod High Very high

Comments:

Potential for Violence toward Others:

Unk.

None Low Mod High Very high

Previous/current counseling/services:

Safety concerns or risk factors not listed (e.g., sex offender, gang activity, suicide risk, criminal activity, substance abuse, history of child abuse/neglect, level of cooperation, stress, economic concerns):

Does referent have a Safety Plan?

Yes (if yes, remind to fax it) No

History of CPS Involvement:

# CPS referrals in last 3 years:

# founded:

Describe:

Court Hearings:

Custody Hearing None

Dependency Review At Risk Youth

Criminal - Youth

Unknown Criminal - Parent

Type of Housing:

Stable Housing

Active Eviction Notice/Proceedings

Temporary Housing (shelter, friend’s home)

Homeless

When was decision made to refer:

Staffing with AAG Court hearing

Staffing with referent’s supervisor Family Team Decision Making meeting

Routine Staffing Child Protection Team meeting

Chronicity Staffing After-hours Intake

Other: Child abuse/neglect investigation

Family Involved with the Military:

Yes No

Family Impacted by Deployment:

Yes No

Special Needs/Other Concerns (pets, weapons in home, household pests, unsafe area, etc.):

Reason for Referral

Attach a separate document or use the back of this form to describe the reason for referral

Expectations for Services:

1.

2.

3.

Primary Caregivers

Caregiver #1 Name:

Caregiver #2 Name:

Marital Status:

Single

Married

Partnered

Divorced

Separated

Widowed

Unknown/prefers not to specify

Employment Status:

Employed

Homemaker/Retired

Not Working - Disabled

Unemployed – public assistance

Unemployed – no public asst.

Student

Marital Status:

Single

Married

Partnered

Divorced

Separated

Widowed

Employment Status:

Employed

Homemaker/Retired

Not Working - Disabled

Unemployed – public assistance

Unemployed – no public asst.

Student

Concerns for Caretaker:

Abuse of children

Emotional

Physical

Sexual

Criminal involvement

Developmental, neurological, or intellectual impairment

Domestic violence

Family conflict

Gang involvement

Home management

Inadequate social support

Learning disability

Legal problems

Neglect of children

Environmental

Medical

Supervisory

Non-/limited English speaker

Parenting concerns

Physical disability

Prostitution

Recent immigrant/refugee

Self-harm/suicidal behavior

Serious health concerns

Serious mental health concerns

Substance abuse or misuse

Alcohol

Crack/cocaine

Hallucinogens

Opioids

Marijuana

Methamphetamines

Other prescription drugs

Transportation

Violent behavior

Concerns for Caretaker:

Abuse of children

Sexual

Domestic violence

Family conflict

Gang involvement

Home management

Legal problems

Neglect of children

Environmental

Medical

Supervisory

Non-/limited English speaker

Parenting concerns

Prostitution

Recent immigrant/refugee

Methamphetamines

Other prescription drugs

Transportation

Youth Identified for Services

Youth #1 Name: Person ID#:

Youth #2 Name:

Person ID#:

Youth referred for: Plcmnt Stab. Reunif. Plcmnt Prev.

Youth referred for: Plcmnt Stab. Reunif. Plcmnt Prev.

Relationship to Caregiver #1

Biological Child

Adoptive Child – Relative

Adoptive Child – Non-relative

Stepchild

Guardianship – Relative

Guardianship – Non-relative

Grandchild

Other Relative

Mate’s Child

Friend

Foster Child – Relative

Foster Child – Non-relative

Relationship to Caregiver #2

Adoptive Child – Non-Relative

Guardianship – Non-Relative

Foster Child – Non-Relative

Relationship to Caregiver #1

Adoptive Child – Non-relative

Foster Child – Non-relative

Relationship to Caregiver #2

Adoptive Child – Non-Relative

Guardianship – Non-Relative

Foster Child – Non-Relative

Living Situation at Referral

Home w/ permanent caregivers

Birth Parent

Adoptive Parent

Relative

Temporarily away from home

Runaway

Staying with friend/relative

Detention/juvenile justice

Psychiatric facility

Crisis placement

Inpatient drug/alcohol tx

Hospital

Informal placement - unpaid

Other

Formal placement - paid

Foster care - Relative

Foster care – Non-relative

Group home/residential care

Long-term psychiatric care

Is this the Permanent Plan?

No Yes

If not, select permanent plan:

Living Situation at Referral

Temporarily away from home

Staying with friend/relative

Detention/juvenile justice

Psychiatric facility

Crisis placement

Inpatient drug/alcohol tx

Hospital

Is this the Permanent Plan?

If not, select permanent plan:

If placed, where would youth most likely be placed:

Informal placement – unpaid

Group home/residential

Other:Other:

If placed, where would youth most likely be placed:

Informal placement – unpaid

Group home/residential

Other:Other:

Is Youth At Risk of Abuse, Neglect or Family Conflict:

offender victim Physical Abuse:

victim Sexual Abuse:

non-physical physical Family Conflict:

environmentalsupervisory physical emotional medical Neglect:

Is Youth At Risk of Abuse, Neglect or Family Conflict:

victim Physical Abuse:

victim Sexual Abuse:

non-physical physical Family Conflict:

environmentalsupervisory physical emotional medical Neglect:

Concerns for Youth:

Child requesting placement

Drug exposed infant

Gang involvement

Inappropriate sexual behavior

Non-/limited English speaker

School drop-out

School suspension/expulsion

School truancy

Sibling abuse

Methamphetamine

Other prescription drugs

Teen pregnancy

Youth below grade level

Concerns for Youth:

Child requesting placement

Drug exposed infant

Gang involvement

Inappropriate sexual behavior

Non-/limited English speaker

School drop-out

School suspension/expulsion

School truancy

Sibling abuse

Methamphetamine

Other prescription drugs

Teen pregnancy

Youth below grade level

Previous Formal Placements

# Foster placements:

# Group home/residential:

# Psychiatric placements:

# Detention/juvenile justice:

Was Youth Adopted:

Age adopted:

Adoption pending? No

Special needs? NoYes

Previous Formal Placements

# Foster placements:

# Group home/residential:

# Psychiatric placements:

# Detention/juvenile justice:

Was Youth Adopted:

Age adopted:

Adoption pending? No

Special needs? NoYes

©Institute for Family Development, Federal Way, Washington ~ 2009

HOMEBUILDER Referral Information Summary Revised 08/09/18

Do not reproduce in whole or part for non-client use without written permission. All rights reserved. Do not post on the Internet.

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Microsoft_Word_97_-_2003_Document3.doc

HOMEBUILDERS( Core Curriculum (4 Days)

This workshop is designed to introduce participants to the program philosophy, program structure and the treatment practice that are fundamental to delivering high quality Homebuilders Family Preservation and Reunification Services.

Participants will learn:

· How to engage and motivate families in the change process

· Structuring strategies for keeping family members and themselves safe

· To develop and implement safety plans

· To conduct a client directed, holistic assessment of family strengths and problems

· To use the North Carolina Family Assessment Scale (NCFAS) to organize assessment information, develop goals and evaluate outcomes

· Strategies for helping clients identify values, strengths and goals

· To use the assessment information to develop outcome-based goals

· To use research-based cognitive/behavioral interventions to help children and families change

· To identify skills and intervention strategies for helping families achieve their goals

· To teach skills to families

· To evaluate progress toward goals

· To plan for maintenance of changes and successful termination of services

· To develop goals and service plans

· To complete required client paperwork and service documentation

Motivational Interviewing

(2 Days)

This training is based on the internationally recognized work of Drs. William Miller and Stephen Rollnick. Motivational Interviewing (MI) is a client-centered approach to helping clients’ better understand and resolve their ambivalence about change. Using Prochaska and DiClemente’s “stages of change” to assess client readiness for change, MI offers effective strategies to use within each stage of change to help overcome client resistance, resolve ambivalence, and ultimately/ideally move the client to action. Originally developed to motivate clients with addictive behavior, MI is now also used to facilitate many different kinds of behavioral change for parents and teens including:

· Engaging clients in services and reducing no-shows

· Providing adequate supervision of children

· Learning and using appropriate methods of discipline

· Willingness to access and utilize treatment for substance abuse/misuse, sexual abuse, mental health and other concerns

· Increasing school attendance

· Following service plans, terms of probation, etc.

· Complying with parental rules and limits

· Working collaboratively with other service providers

Participants attending this training will learn to:

· Assess the client’s Stage of Change and identify appropriate M I strategies to use

· Engage clients and elicit greater participation in services

· De-escalate clients and avoid conflict

· The Spirit of M I and how to incorporate this spirit into their work

· Refine their use of reflective listening and other essential skills

· Resolve client ambivalence and tap into intrinsic motivation

· Elicit client change without argument or “resistance”

· Apply concepts to current case examples

Relapse Prevention

(1 Day)

This workshop provides an introduction to the evidence-based strategies for addressing and preventing relapse of addictive and other behavioral problems. Based on the work on Alan Marlatt, Ph.D., Michler Bishop, Ph.D. and others, the strategies utilize cognitive/behavioral principles and are congruent with the "Wheel of Change" framework and Motivational Interviewing. Although focused on the principles related to substance use/abuse, the strategies presented also apply well to other types of behavioral and cognitive changes. Participants will receive a variety of tools to use with clients to help them assess their risks, develop individually tailored plans, and implement skills for a more successful future.

Participants will learn to:

· Identify the predictors of relapse

· Help clients assess high risk situations and identify triggers

· Help clients use cognitive and behavioral coping skills for responding to triggers

· Help clients challenge their "positive outcome expectancies" for using drugs/alcohol

· Help clients recognize "apparently irrelevant decisions" affecting relapse

· Help clients manage lapses and prevent "goal violation effect"

· Help clients develop plans for life-style balance and self-care

· Help clients develop and use tools for self control

Implementing Cognitive and Behavioral Strategies with Clients and Teaching Skills to Families

(3 Days ~ Delivered as a 3 day workshop, or individual workshops – Cognitive Strategies -1 day; Behavioral Strategies - 1 day;

Teaching Skills – 1 day) )

This workshop provides more in depth instruction and practice of key cognitive and behavioral intervention strategies. The goal of the training is to help practitioners develop individually tailored and effective cognitive and behavioral interventions that go beyond behavior and chore charts. Participants will practice using Rational Emotive Behavioral Therapy (REBT), reframing and other cognitive strategies and learn to identify common cognitive distortions and how to address these in their work with families. Behavioral strategies addressed and practiced during the workshop include conducting a Functional Behavioral Analysis and developing interventions based on the analysis. Participants will learn to use Positive Behavior Support strategies and to develop both antecedent and consequence based interventions. Participants will learn and practice using the “teaching interaction” to role play and practice a number of skills to teach parents and children (e.g. praise, following instructions etc)

· Rational Emotive Behavior Therapy (REBT) and other cognitive strategies with families

· To identify cognitive distortions and when and how to use cognitive interventions

· To conduct a functional behavioral assessment and develop intervention strategies based on the analysis

· Positive Behavior Support strategies and interventions

· To develop and evaluate antecedent and consequence based interventions

· To design and use behavioral charts, contract and reinforcement systems

· To identify specific skills to teach parents and children based on the functional analysis

· To use the “Teaching Interaction” to actively teach identified skills

· To prompt, coach and reinforce parents’/childrens’ use of new skills.

Improving Decision Making Through Critical Thinking

"Critical thinking" refers to the active process of trying to minimize the influence of preconceptions and biases while rationally evaluating evidence, making decisions based on the evidence, and considering alternative explanations. The process of critical thinking involves the careful examination of assumptions, beliefs, evidence, and information that can improve assessments, service/treatment planning, interventions, and ongoing evaluation of clinical and casework practice. This workshop introduces a "critical thinking framework" and specific strategies and tools to encourage critical thinking and improved decision making throughout child welfare practice. This workshop is designed for child welfare/mental health practitioners, supervisors and administrators who make critical decisions regarding children, youth and families.

· A critical thinking/reflective practice framework for improving decision making

· How to think critically about assessment, planning, and implementation

· 18 common “errors in thinking” and their countermeasures

· How to evaluate their own thinking and decision making

· To assess the influence of their "personal framework" on their work

· To actively "question" and generate "critical thinking questions" to gather and clarify information

· How to develop a "Culture of Thoughtfulness" (encourage Critical Thinking) in their organizations

Working with Families with Domestic Violence

This workshop for home-based practitioners and supervisors is based on the curriculum developed by the Institute staff and national experts in the field of domestic violence. The goal of the workshop is to provide participants with a framework for defining and understanding domestic violence, and the tools and skills for assessing domestic violence and developing intervention strategies.

· To identify domestic violence

· To understand common reactions to victimization

· To understand their own reactions to victimization

· To identify helpful responses to victimization

· The variety of reactions children might have to domestic violence

· Intervention strategies to use with victims of domestic violence and their children

· To assess safety and develop safety plans and options

Ethical Issues in In-Home Services (1 Day)

Working intensively in family homes creates a variety of ethical dilemmas never encountered in office settings. This training is designed specifically for intensive home based service providers. Each participant is required to bring a copy of their professional Code of Ethics which is used as a resource during the training.

Training topics include:

Contrasting Teleontological and Deontological Ethics

Confidentiality

Standard of Care

Negligence

Boundary Issues:

· Boundary Violations and Boundary Crossings

· Relationships

· Emotional and Dependency Needs

· Unavoidable and Unanticipated Circumstances

Electronic Communications

Working in small groups, participants identify work-related ethical issues dilemmas and apply an Ethical Decision Making Process to an ethical issue.

Fundamentals of Supervising HOMEBUILDERS(

Intensive Family Preservation Services

(2-2.5 Days)

This workshop addresses the multi-faceted roles of family preservation supervisors and managers. The training includes strategies and tools for managing worker and program performance, staff selection and hiring, clinical consultation, preventing staff burnout, and developing community linkages and support.

· Primary responsibilities of the Homebuilders/IFPS Supervisor

· To conduct and structure group and individual consultation

· To work with referring workers to ensure appropriate referrals

· Staff selection and hiring strategies and processes

· To manage supervisor and therapist stress and prevent burnout

· Field training of new staff and ongoing staff development

· To model program values and strategies

· Homebuilders Standards and the supervisory and therapist components

· To promote and support the IFPS model

· To develop and maintain community relations

Responsive Supervision: Core Competencies

Preventing and Solving Employee Work Problems and Improving Team Coordination

(1.5-2.5 Days)

This workshop is designed for a broad range of supervisors and managers and focuses on the primary roles of the supervisor and implementing processes for providing ongoing feedback to staff, improving staff performance and strategies for handling and solving employee work problems and for facilitating and improving team coordination and performance. Participants will receive the “S3”, a staff satisfaction survey for providing useful feedback to supervisors and managers, the Catalyst®, a communications tool, and other workshop materials and useful manuals.

· The four primary roles of a supervisor and key supervisory skills

· Skills of providing positive feedback and performance based rationales

· Skills of providing negative/corrective performance feedback and improving individual and team performance

· Skills of providing negative/corrective feedback to unreceptive staff

· Skills for handling interpersonal conflicts

· Skills for preventing staff interpersonal and work related problems

· The IDEAS process for prioritizing issues, setting goals and developing consensus

· An effective process for facilitating meetings

Institute for Family Development ( 34004 16th Avenue South, Suite 200 (Federal Way, WA 98003-8903

Phone: Seattle (253) 874-3630 ( Tacoma (253) 927-1550 ( Fax (253) 838-1670 ( www.institutefamily.org image7.emf

Microsoft_Word_Document.docx HOMEBUILDERS® Supervisor Level System Checklist

Criteria for Moving From Level 1 to Level 2

Consultant: Date Supervisor Advanced to Level Two:

Site: Supervisor:

1. Demonstrates the ability to identify and adequately address safety concerns for families and staff.

Yes

No

Comments:

2. Follows Homebuilders guidelines for when to contact the Homebuilders consultant.

Yes

No

Comments:

3. Receives a preponderance of 3s and no 1s on the most recent Home Visit Observation conducted by a consultant or Level 4 supervisor.

Yes

No

Comments:

4. Meets the fidelity measure below for shadowing each therapist on the team: Supervisors accompany each therapist at least quarterly for therapists with fewer than two years Homebuilders experience, and at least semi-annually for therapists with more than two years Homebuilders experience.

Yes

No

Comments:

5. Meets the fidelity measures below, or is on track to complete the individualized training plan, developed with the consultant, regarding the initial on-the-job training of new therapists.

a. New therapists shadow the supervisor or an experienced therapist on at least one complete intervention.

b. The supervisor shadows therapists on the equivalent of at least one intervention in which the therapist takes primary responsibility. This can occur during a single intervention or be spread over the first two to four interventions.

Yes

No

Comments:

6. Has completed at least three of the six interventions required for new supervisors without prior Homebuilders experience. Two of these may be interventions in which the supervisor was the lead therapist while training a new therapist.

Yes

No

Comments:

7. Scores an average rating of 5 or above on each question on the most recent Therapist Feedback for Supervisor survey.

Yes

No

Comments:

8. Scores a majority of 3s and no 1s on the most recent Homebuilders Consultation Review – Supervisor.

Yes

No

Comments:

9. Has participated fully in all required training and QUEST activities.

Yes

No

Comments:

10. Demonstrates the ability to follow the Homebuilders Paperwork Guidelines in completing the supervisor’s own client documentation, as well as in reviewing the documentation of staff.

Yes

No

Comments:

11. Demonstrates the ability to screen for appropriate referrals.

Yes

No

Comments:

12. Demonstrates critical thinking when requesting consultant approval of extensions.

Yes

No

Comments:

13. Uses a system to ensure accurate, complete, and timely clinical documentation in ECM.

Yes

No

Comments:

©Institute for Family Development, Federal Way, Washington ~ 2013 Page 2 of 2

HOMEBUILDERS Supervisor Level 2 Checklist 1.1 Revised 10/18/18

Do not reproduce in whole or part for non-client use without written permission. All rights reserved. Do not post on the Internet.

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Microsoft_Word_Document1.docx Homebuilders Clinician Survey

Please rate your supervisor in each of the following areas. Average ratings will be provided to your supervisor in aggregate form. Ranges (high and low scores) may also be shared. Because of using Qualtrics, survey respondents will be unable to be identified.

How satisfied are you that your supervisor models and reinforces behavior consistent with HOMEBUILDER's values and beliefs?

(e.g., It's best for children to be raised by their own family whenever possible; safety is our highest priority; clients are our colleagues and partners; teaching skills empowers clients, we can't predict which situations are most amenable to change; it is our job to motivate clients and instill hope; all people have the ability to change; crisis is an opportunity for change; we are respectful of each client's culture, ethnicity, and religious beliefs; family members do not usually intend to harm one another; people are doing the best they can; inappropriate intervention can do harm.)

Very satisfied

Satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

How satisfied are you with your supervisor's help in applying a cognitive/behavioral approach, and in selecting the cognitive and behavioral strategies that are most likely to help family members achieve desired outcomes?

Very satisfied

Satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

How satisfied are you with your supervisor's efforts to help you assess the effectiveness of your interventions with families?

Very satisfied

Satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

How satisfied are you that your supervisor provides adequate support in the following areas (please rate each area separately):

Very Satisfied

Satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

Is available for immediate consultation needs on a 24/7 basis

Responds to calls, pages, and email messages in a timely manner

Appropriately arranges for back-up whenever he/she will be unavailable to respond to immediate consultation needs, and ensures you have contact information for the designated back-up person

Would go out with you on home visits if needed or requested for support

Would accompany you to formal client-related meetings (e.g., Shared decision-making meeting, CPT, FTDM, Family-Team meeting, etc.) if needed or requested for support

Provides an adequate amount of positive and constructive feedback

How satisfied are you with your supervisor's efforts to help you identify and address:

Client safety risks?

Very satisfied

Satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

Potential risks to your own safety?

Very satisfied

Satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

How confident are you in your supervisor's clinical expertise and judgment?

Very satisfied

Satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

How satisfied are you with your supervisor's efforts to help you improve your client documentation (provides rationales for changes, discusses needed changes, etc.)?

Very satisfied

Satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

How satisfied are you that your supervisor creates a comfortable, supportive learning environment? (Please rate each area below separately):

Very Satisfied

Satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Dissatisfied

Very dissatisfied

Encourages and utilizes a teamwork approach

Elicits team members' participation during team consultation

Receives and utilizes feedback well

Maintains an atmosphere in which staff feel they can discuss issues with candor and mistakes are viewed as opportunities for learning

On a scale from 0-10, how likely are you to recommend working at Bethany to a friend or family member?

Extremely unlikely

Extremely likely

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Microsoft_Word_Document2.docx Homebuilders Parent Survey

Please complete:

Your Last Name ________________________________________________

Homebuilders Worker Name ________________________________________________

Which state do you live in?

· Indiana

· Rhode Island

· South Carolina

Thank you for taking the time to complete this survey. We will use this information to help improve our services. Please feel free to include negative comments, as they help us identify areas for improvement. If you need more space for comments, please attach additional pages. If you prefer to complete the survey by phone, or if you have questions, additional comments or concerns you wish to share with us, please call:

Indiana:

Jennifer Phillips – supervisor at (317) 989-3214

Jessica Norris – practitioner at (317) 965-3969

Twilla Brohman – practitioner at (317) 340-0015

Rhode Island:

Stephanie Marratta at 401-428-1310

Cassandra Steere at

Colbert Barionnette a

South Carolina:

Alan C. Altman, Homebuilders Supervisor Office Phone: 843-353-6595 Work Cell Phone: 706-329-9018

Phillip Trammel, Homebuilders Therapist Office Phone: 843-353-6595 Cell Phone: 706-329-2198

How satisfied were you that your worker listened to you and understood your situation?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

Did your worker schedule visits at times that were convenient for you?

· Yes

· No

· Sometimes

About how often did you or other family members meet with your worker?

· 1 time per week

· 2-3 times per week

· 4 or more times per week

Did your worker tell you he/she was available to you 24 hours a day, 7 days per week and encourage you to call whenever needed?

· No

If you called your worker asking for help, did he/she respond in a timely manner?

Always

Most of the time

Sometimes

Rarely

Never

I did not call for help

How satisfied were you that your worker was respectful of your family’s culture and values?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

Did your worker help you and/or other family members learn new skills?

· Yes

Are you using these new skills? Please list new skills you are using in the comments section.

· Yes

Comments

How is the situation for your family now, compared to when you first began working with your worker?

A lot better

A little better

About the same

A little worse

A lot worse

Did your worker help you get connected with resources or ongoing services in the community?

· Yes

· Not needed

Is there anything that your worker could have done that might have been more helpful? If so, please tell us what would have been more helpful in the comments section.

Comments

Overall, how satisfied were you with the services you received?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

Can we share your feedback with your worker?

Is there anything else you would like to say about your worker or the services you received?

How likely are you to recommend Bethany Christian Services Homebuilders program to a friend?

Extremely unlikely

Extremely likely

Thank you for your feedback. Would you like someone from Bethany to call you so you can provide more information about your answers?

If you would like someone from Bethany to call you so that you can share additional information about your answers, please provide your name and phone number.

Name ________________________________________________

Phone Number ________________________________________________ image10.emf

Microsoft_Word_Document3.docx Homebuilders Referring Worker Survey

Please complete:

Family Name _____________________________________________

Homebuilders Worker Name _____________________________________________

Referring Worker Name _____________________________________________

Which state does the family live in? _____________________________________________

Please answer the following questions using the scale provided. Mark N/A if you don't have enough information to answer. Please include comments regarding your responses.

How satisfied were you with your working relationship with the worker (i.e., was the worker responsive, accessible, professional, etc.)?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Somewhat dissatisfied

Not applicable

Did you have adequate contact with the worker?

How satisfied were you that the treatment goals were appropriate for this family and addressed the concerns you identified in the referral?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Somewhat dissatisfied

Not applicable

How satisfied were you that the worker adequately addressed safety issues?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Somewhat dissatisfied

Not applicable

How satisfied were you that the services provided were responsive to the family (i.e., tailored to their culture, values, learning style, etc.)?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Somewhat dissatisfied

Not applicable

Given the family’s situation, how satisfied were you overall with the outcome of the intervention?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Somewhat dissatisfied

Not applicable

Overall, how satisfied were you with the services the family received?

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Somewhat dissatisfied

How likely are you to recommend Bethany Christian Services Homebuilders program to a colleague?

Extremely unlikely

Extremely likely

Revised 6/26/20 – Institute for Family Development image11.emf

Microsoft_Word_97_-_2003_Document.doc HOMEBUILDERS® Site Review

Site:

Review Period:

Supervisor:

Consultant:

Completed by:

Date Completed:

Executive Summary

Brief summary of the results of the Homebuilders Site Review

Intervention Summary

Summary of interventions included in the data for this site review

Row Labels

Total Referrals

Eligible Referrals

% Eligible

Ineligible Referrals

% Ineligible

Grand Total

Row Labels

Eligible Referrals

Interventions that closed prematurely (eligible referrals only)

% closed prematurely

Interventions that did not close prematurely (eligible referrals only)

% not closed prematurely

Grand Total

Program Success Rate

Overall success rate

Placement Prevention / Reunification Achieved at Closure*

Completed Interventions

Row Labels

Youth Referred

PP or R Achieved

Percent of Youth with PP or R Achieved

Grand Total

Placement Prevention / Reunification Achieved at Closure*

Interventions that Closed Prematurely

Row Labels

Youth Referred

PP or R Achieved

Percent of Youth with PP or R Achieved

Grand Total

*Placement prevention and reunification success rates are based on preliminary data at the time of service closure. 6-month success rate data are not available at this time.

NOTE: If 6 month placement data are available, revise this section as needed.

Consumer Feedback

Client Feedback

Row Labels

Families

Percent Reported Therapist Explained 24/7

Client called for help

Percent Reported Therapist Responded in a Timely Manner

Percent Reported Using New Skills

Average Therapist Listened and Understood

Average Therapist Respected Culture and Values

Average Overall Satisfaction

Grand Total

Referent Feedback

Row Labels

Families

Percent Reported Adequate Contact with Referent

Average Satisfaction with Working Relationship

Average Satisfaction with Treatment Goals

Average Satisfaction that Safety Concerns were Addressed

Grand Total

Summaries of client and referent data are listed above. As part of the site review, also review the complete client and referent feedback summaries (including comments). Specific fidelity measures regarding the feedback are included in the sections below. General comments about client and referent feedback can be included here.

QE Plan needed Professional Development Plans needed for (specify staff):

QI Plan needed

Review of Adherence to Homebuilders Standards

Detailed review of adherence to Homebuilders standards and fidelity measures, including data charts when applicable, and determination of which standards need to be included in a Quality Enhancement Plan, Professional Development Plan or Quality Improvement Plan.

Instructions

· Filter all ODM reports for review period (and site if applicable).

· Data charts for most quantitative measures are included with the applicable standard. All client and referent feedback is reported in the charts above. Refer to these charts when addressing measures about client or referent feedback.

· Comments can be brief, but should address each fidelity measure in the comments sections. It is not necessary to repeat data represented in the charts. More narrative comments are needed for qualitative measures, as information about them is not represented in the data charts.

· Comments that are not related to a specific fidelity measure, but relate to overall adherence to a standard, may be included if needed.

· If a Quality Enhancement Plan is needed for the site, mark the box for each standard that needs to be addressed in the plan.

· If any individual team member requires a Professional Development Plan, mark the box for each applicable standard, and indicate the name(s) of the team member(s).

· If a Quality Improvement Plan is needed, mark the box for each applicable standard, and indicate whether the QI Plan is needed for the entire site, or for individual team member(s). If the plan is for an individual, indicate the name(s) of the team member(s).

Specific Target Population

Using the Fidelity – Reason for Referral ODM report, the Homebuilders consultant reviews the “reason for referral” from the 10 most recent eligible interventions from the review period to determine if the referrals meet the established eligibility requirement (listed below).

Placement Prevention Eligibility Requirements

Reunification Eligibility Requirements

If IFPS is not available, one of the following will occur:

· Children will be placed in protective custody;

· Court petition will be filed requesting placement;

· Voluntary placement agreement will be initiated.

Less intensive services have been exhausted, or the referent does not believe they are appropriate.

Maintaining the child in the home is not just a temporary plan. The child is not on a waiting list or pending entry into group care, psychiatric care, or a juvenile justice institution.

The caregiver has been informed of the risk of placement.

The child is in placement and will return home within 7 days of the start of services

It is an unusually complex situation (e.g., caregiver or child ambivalence, disrupted attachment, unresolved risk factors, legal issues, caregiver lacks understanding of child treatment needs, etc.).

The referent believes less intensive reunification services will not suffice to address the reunification concerns.

The referent has confirmed the caregiver will be available for an intake session within 24 hours of referral.

The referent has described the intensity of IFPS to the family, and at least one caregiver in the home is available to participate.

Comments:

90% of sampled referrals (excluding ineligible referrals) meet eligibility criteria, as described in the reason for referral.

Values Based Orientation

The primary sources for this measure include: Home visit observations, file reviews, and consultation review.

Comments:

Staff use behaviorally specific, value neutral language and avoid the use of labels and inferences in all communication.

Immediate Availability and Response to Referrals

Row Labels

Families

Resp Time within 24

Percent Resp Time within 24

Intake by Next Day

Percent Intake by Next Day

Avg Resp Time

Max Resp Time

Min Resp Time

Grand Total

Comments:

75% of families receive their first face-to-face visit within 24 hours of referral; 85% of families receive their first face-to-face visit no later than the end of the day after the referral (based on all eligible referrals).

Twenty-Four Hour Availability

Summarize the answers to the second and third measures (policies about flexible work schedule, and agency information given to clients) based on information about site practices and procedures, including the agency’s written program information provided to clients. Review client feedback data (above) to address the final two measures.

Row Labels

Interventions

Number of families who live within an hour’s drive

Percent of families who live within an hour’s drive

Average 1-way travel time

Grand Total

Comments:

Therapists live within an hour’s drive of 80% of clients served.

Provider agency policies specifically allow a flexible work schedule, with work hours varying from week to week based on the needs of families.

The agency’s written program information given to clients includes specific information regarding the therapist’s 24/7 availability and back-up.

90% of family members who answer the question “Did your therapist explain 24/7 availability” on the Homebuilders Client Feedback Survey answer “Yes.”

Of the family members who report on the Homebuilders Client Feedback Survey that they called their therapist, 90% answer “Always” to the question “If you called your therapist asking for help, did he/she respond in a timely manner?”

Service Provided in the Client’s Natural Environment

Row Labels

Total FF Sessions

Total In Home Sessions

Percent of sessions in home

Grand Total

Comments:

At least 80% of all…