gao-Trauma-Informed Care - Challenges to Developing and Implementing Performance Partnership Pilots to Serve Children-此为英文文档

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GAO-23-106538Trauma-InformedCare

August18,2023

TheHonorableTammyBaldwin

Chair

TheHonorableShelleyMooreCapitol

RankingMember

SubcommitteeonLabor,HealthandHumanServices,Education,andRelatedAgenciesCommitteeonAppropriations

UnitedStatesSenate

TheHonorableRobertAderholt

Chair

TheHonorableRosaDeLauro

RankingMember

SubcommitteeonLabor,HealthandHumanServices,Education

CommitteeonAppropriations

HouseofRepresentatives

Trauma-InformedCare:ChallengestoDevelopingandImplementingPerformancePartnershipPilotstoServeChildren

Traumaisawidespread,harmful,andcostlypublichealthproblem.Anyfrightening,dangerous,orviolenteventthatthreatensthelifeorsafetyofachildortheirlovedonescanpotentiallybetraumatic.Aswereportedin2019,traumasignificantlyincreasestheriskofproblemswithmentalandphysicalhealth,socialrelationshipsandbehavior,andschoolperformance.

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Manychildrenandfamiliesaffectedbytraumareceiveservicesthroughmultiplesystems,suchaschildwelfare,healthcare(includingbehavioralhealthcare),juvenilejustice,andschools.Theseservicesmayincludetrauma-informedcare,whichcanrefertoevidence-basedinterventions(treatment)orabroaderapproachthatintegratespracticesthroughoutaservicedeliverysystem(anorganizationalcultureorparadigmshift).Toensurethatyouthreceivetrauma-informedcareacrosssystemsandinacoordinatedmanner,communitiesneedsupporttobuildinfrastructureandcapacity.

Congressmayauthorizeavarietyofapproachestohelpbuildinfrastructureandcapacity.Performancepartnershipsareoneapproach.Performancepartnershipsallowafederalagencyormultiplefederalagenciestoprovidegrantrecipientsflexibilityinhowtheyusefundingacrosstwoormoreprograms,amongotherflexibilities.Inexchangefortheseflexibilities,recipientscommittoimproveagreed-uponoutcomesandassessprogresstowardsthem.SenateReport115-150includesaprovisionforusto,amongotherthings,identifybarriersorchallengesfacedbyorganizationsthatreceivefundingfrommultiplefederalprogramstoservechildrenexposedtotrauma.Thisreportexamineschallengesstateandlocalgovernmentsandother

1GAO,ChildrenAffectedbyTrauma:SelectedStatesReportVariousApproachesandChallengestoSupportingChildren,

GAO-19-388

(Washington,D.C.:April24,2019).

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GAO-23-106538Trauma-InformedCare

organizationsmightfaceinusingperformancepartnershippilotstoservechildrenexposedtotrauma.

Toaddressthisobjective,wereviewedPerformancePartnershipPilotsforDisconnectedYouth(P3)reportsandissuebriefs;

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BuildingaMulti-SystemTrauma-InformedCollaborative:AGuideforAdoptingaCross-System,Trauma-InformedApproachAmongChild-ServingAgenciesandTheirPartners;

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federalagencydocuments;andpriorGAOreports.Inaddition,weinterviewedaformerOfficeofManagementandBudgetofficialwhohelpedcreateandimplementperformancepartnershippilotsfordisconnectedyouth.WealsointerviewedindividualswhoprovidedtechnicalassistancetoandwrotetheguideabouttheMulti-SystemTrauma-InformedCollaborative,andSubstanceAbuseandMentalHealthServicesAdministrationofficialswhofacilitateandcoordinatetheworkofthefederalInteragencyTaskForceonTrauma-InformedCare.

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Throughourreviewofdocumentsandinterviewsweidentifiedchallengesthatstateandlocalgovernmentsandotherorganizationsmayfaceindevelopingandimplementingperformancepartnershippilotstoservechildrenexposedtotrauma.

WeconductedthisperformanceauditfromJanuary2023toAugust2023inaccordancewithgenerallyacceptedgovernmentauditingstandards.Thosestandardsrequirethatweplanandperformtheaudittoobtainsufficient,appropriateevidencetoprovideareasonablebasisforourfindingsandconclusionsbasedonourauditobjectives.Webelievethattheevidenceobtainedprovidesareasonablebasisforourfindingsandconclusionsbasedonourauditobjectives.

OnJune29,2023,webriefedSenatestaffonthepreliminaryresultsofthisstudy.Thisreportformallyconveystheinformationprovidedduringthisbriefing,assummarizedbelow(seeenclosureIforthebriefingslides).

•Stateandlocalgovernmentsandotherorganizationsmayfinditdifficulttogetpartnerstocoalescearoundperformancepartnershippilotstoservechildrenexposedtotrauma.AccordingtoMathematica,trustandbuy-inwerekeyfactorsthatinfluenceP3programs’useoftheflexibilitiesaffordedtothem.Leadershipinfiveofthe14P3programsnotedthattheywereunabletosecureenoughtrustandbuy-infromtheirstateandlocalpartnerstoimplementtheirplannedapproaches.AmericanInstitutesforResearch(AIR)officialstoldusthatstatesweredelayedinbeginningtheirworkbyabout6months,inpart,becauseittooktimetogetpeopleengagedintheinitiative.

•Stateandlocalgovernmentsandotherorganizationsmayfinditdifficulttoachievetheirgoals,includingsystemschange,iftheydonothavesufficienttimeforplanning.AIRofficials

2Congresshasauthorizedtwofederalperformancepartnershipinitiatives,theEnvironmentalProtectionAgency’sPerformancePartnershipGrantsandthemulti-agencyPerformancePartnershipPilotsforDisconnectedYouth(P3).ToevaluateP3,theDepartmentofLabor,in2015,awardedMathematicaandSocialPolicyResearchAssociatesa5-yearcontract.

3TheBuildingaMulti-SystemTrauma-InformedCollaborativeguidewasdevelopedbyChapinHallandtheAmericanInstitutesforResearch.Theguidesummarizeslessonslearnedbythreestates’efforts—Connecticut,Illinois,Washington—tobuildthecapacityofstatechild-servingsystemstodevelop,coordinate,andenhancepoliciesandpracticesforservingyouthexposedtoviolenceandothertraumas.

4TheSUPPORTforPatientsandCommunitiesAct(Pub.L.No.115-271)includedaprovisiontoestablishtheInteragencyTaskForceonTrauma-InformedCare.Thetaskforceischargedwithidentifying,evaluating,andmakingrecommendationsregarding(1)bestpracticeswithrespecttochildren,youth,andtheirfamilieswhohaveexperiencedtraumaorareatriskofexperiencingtrauma;and(2)waysfederalagenciescanbettercoordinateresponsestofamiliesaffectedbysubstanceusedisordersandotherformsoftrauma.

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toldusthatplanningentailsgettingpeopletothetable;determininginfrastructure;assessingagencies’knowledge,understanding,practices,andpolicies;andmappingresources.AIRofficialsnotedthatifasystemisnotsetupwellandtheplanningprocessisskipped,thenmoneyforservicesmaynotbeusedeffectively.Mathematicaconcludedthatdedicatedplanningtimecouldsupportaccomplishingfoundationalworkforsystemschange.

•Datasharingwouldbecentraltodevelopingandimplementingperformancepartnership

pilotsandtrauma-informedsystems;however,severalissues,suchasprivacyconcerns,mayunderminedatasharingefforts.MathematicareportedthatthesevenpilotsthatplannedtoincorporatedatasharingintotheirP3approachwerehamperedbythelackofcapabilitiesamongexistinginformationsystems.Inaddition,theywerehamperedbythetimeandeffortinvolvedingettingallpartiestobuyintodatasharing,agencies’desiretomaintaintheirowninformationsystems,andconfidentialityconcerns.However,accordingtoAIRofficials,individualsneedtosharedataacrossagenciestopreventfamiliesfromhavingtorepeatedlyprovidethesameinformationtomultipleagencies,whichmayre-traumatizechildrenandfamilies.

AgencyComments

WeprovidedthebriefingslidestotheDepartmentofHealthandHumanServicesforreviewandcomment.HHSprovidedtechnicalcomments,whichweincorporatedinthereportasappropriate.

Ifyouandyourstaffhaveanyquestions,pleasecontactKathrynA.Larinat(202)512-7215or

larink@

.ContactpointsforourOfficesofCongressionalRelationsandPublicAffairsmaybefoundonthelastpageofthisreport.MajorcontributorstothisreportwereSaraSchibanoffKelly(AssistantDirector),RamonaL.Burton(AnalystinCharge),AndreaDawson,DanaHopings,JeanMcSween,MimiNguyen,JenniferPadgett,JamesRebbe,AlmetaSpencer,andAdamWendel.

KathrynA.Larin,Director

Education,Workforce,andIncomeSecurityIssues

Enclosure-I

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Formoreinformation,contactKathyrnA.Larin

Trauma-InformedCare:Challengesto

DevelopingandImplementingPerformancePartnershipPilotstoServeChildren

ABriefingtoCongressionalCommittees

June29,2023

UpdatedonAugust2,2023

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Agenda

•Objective

•Background

•ScopeandMethodology

•Findings

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Objective

•Whatchallengesmightstateandlocalgovernmentsandotherorganizationsfaceinusingfederalprogramstodevelopandimplementperformancepartnershippilotstoservechildrenexposedtotrauma?

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Background:Trauma

•Traumaisawidespread,harmful,andcostlypublichealthproblem.Anyfrightening,dangerous,orviolenteventthatthreatensthelifeorsafetyofachildortheirlovedonescanpotentiallybetraumatic.Whilenoteverychildwhoexperiencestraumawillsufferlastingeffects,studieshaveshownthatformanythereareseriousshort-andlong-termconsequences.

•AsGAOreportedin2019,traumasignificantlyincreasestheriskofproblemswithmentalhealth,socialrelationshipsandbehavior,physicalillness,andschoolperformance.

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Background:Trauma-InformedCare

•Trauma-informedcarecanrefertoeitherevidence-basedinterventions(treatment)ortoabroadersystem-levelapproachthatintegratespracticesthroughoutaservicedeliverysystem(anorganizationalcultureorparadigmshift).

•AccordingtotheSubstanceAbuseandMentalHealthServicesAdministration,trauma-informedapproaches:

(1)realizethewidespreadimpactoftraumaandunderstandpotentialpathsforrecovery;

(2)recognizethesignsandsymptomsoftraumainclients,families,staff,andothersinvolvedwiththesystem;

(3)respondbyfullyintegratingknowledgeabouttraumaintopolicies,procedures,andpractices;and

(4)seektoactivelyresistre-traumatization.

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Background:AComprehensiveApproachto

AddressingTrauma

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Background:Trauma-InformedCare,cont.

•Manychildrenandfamiliesaffectedbytraumareceiveservicesthroughmultiplesystems,suchaschildwelfare,healthcare(includingbehavioralhealthcare),juvenilejustice,andschools.

•Ensuringthatallservicedeliverysystemsadoptatrauma-informedapproachallowschildren,youth,andtheirfamiliestobuildresilienceandhealinenvironments,accordingtotheSubstanceAbuseandMentalHealthServicesAdministration.

•Toensurethatyouthreceivetrauma-informedcareacrosssystemsandinacoordinatedmanner,communitiesneedsupporttobuildinfrastructureandcapacity.

•Congressmayauthorizeavarietyofapproachestohelpbuildinfrastructureandcapacity.Performancepartnershipsareoneapproach.

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Background:PerformancePartnerships

•Performancepartnershipinitiativesallowafederalagencyormultiplefederalagenciestoprovidegrantrecipientsflexibilityinhowtheyusefundingacrosstwoormoreprogramsalongwithadditionalflexibilities.Inexchangefortheseflexibilities,recipientscommittoimproveagreed-uponoutcomesandassessprogresstowardsthem.

•Authorizedinfiscalyear2014,PerformancePartnershipPilotsforDisconnectedYouth(P3)allowedfundingfrommultipleprogramsacrossmultipleagenciestobecombinedintopilotprogramsservingyouthwhoaredisconnectedfromschoolandwork.

•Theauthorityenabledpilotsitestoblendfederalfundsandobtainwaiversofprogramrequirements,includingrequirementsthatarebarrierstoachievingimprovedoutcomesforyouth-servingprogramsdescribedintheauthority.

•Seventeenstate,local,andtribalcommunitieshaveparticipatedinP3sinceCongressinitiallyauthorizedit—nineinFY2014,oneinFY2015,fiveinFY2016,andtwoinFY2022.

•Toimplementtheirapproachestoservingdisconnectedyouth,allpilotsbroughttogetherpartnersacrossworkforcedevelopment,education,andotherdomains.

FY2016.OnecommunitywithdrewfromparticipatinginP3.

1Mathematica’sevaluationfocusedon14of15state,local,andtribalcommunitiesthatwereawardedpilotsfromFY2014throughPage12

ScopeandMethodology

Toaddressourobjective,wereviewed:

PerformancePartnershipPilotsforDisconnectedYouth(P3)reportsandissuebriefs

•ToevaluateP3,theDepartmentofLabor,in2015,awarded

MathematicaandSocialPolicyResearchAssociatesa5-

yearcontract.Overthecourseoftheevaluationperiod,the

reportsdocument14ofthepilots’effortsto,amongother

things,promotesystemschangeatthestateorcommunity

level.1Mathematicadefinedsystemschangeaschangesin

howpartneragenciesineachpilotworkedtogether

throughtheirgovernancestructures,communication

practices,anddata-sharingapproaches.

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ScopeandMethodology

Wealsoreviewed:

BuildingaMulti-SystemTrauma-InformedCollaborative:AGuideforAdoptingaCross-System,Trauma-InformedApproachAmongChild-ServingAgenciesandTheirPartners

•In2016,theU.S.DepartmentofJustice,OfficeofJuvenileJusticeandDelinquencyPrevention,launchedtheMulti-SystemTrauma-InformedCollaborative(MSTIC)tobuildthecapacityofstatechild-servingsystemstodevelop,coordinate,andenhancepoliciesandpracticesforservingyouthexposedtoviolenceandothertraumas.

•Theguide,developedbyChapinHallandtheAmericanInstitutesforResearch(AIR),summarizeslessonslearnedbythreestateteams’cross-systemsefforts—Connecticut,Illinois,Washington.

FederalagencydocumentsandpriorGAOreports

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ScopeandMethodology

Weconductedinterviewswith:

•aformerOfficeofManagementandBudget(OMB)officialwhohelpedcreateandimplement

performancepartnershippilotsfordisconnectedyouth,

•individualswhoprovidedtrainingandtechnicalassistancetoandwrotetheguideaboutMSTIC,

and

•SubstanceAbuseandMentalHealthServicesAdministrationofficialswhofacilitateand

coordinatetheworkofthefederalInteragencyTaskForceonTrauma-InformedCare.

Throughourreviewofdocumentsandinterviewsweidentifiedcommonanduniquechallengesthat

stateandlocalgovernmentsandotherorganizationsmayfaceindevelopingandimplementing

performancepartnershippilotstoservechildrenexposedtotrauma.

WeconductedthisperformanceauditfromJanuary2023toAugust2023inaccordancewithgenerally

acceptedgovernmentauditingstandards.Thosestandardsrequirethatweplanandperformtheaudit

toobtainsufficient,appropriateevidencetoprovideareasonablebasisforourfindingsand

conclusionsbasedonourauditobjectives.Webelievethattheevidenceobtainedprovidesa

reasonablebasisforourfindingsandconclusionsbasedonourauditobjectives.

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Finding

Buy-InfromPartnersMayBeDifficulttoObtain

Stateandlocalgovernmentsandotherorganizationsmayfinditdifficulttogetpartnerstocoalescearoundperformancepartnershippilotstoservechildrenexposedtotrauma.

•AccordingtoMathematica,trustandbuy-inwerekeyfactorsthatinfluenceP3s’useoftheflexibilitiesaffordedtothem.

•Leadershipinfiveofthe14P3snotedthattheywereunabletosecureenoughtrustandbuy-infromtheirstateandlocalpartnerstoimplementtheirplannedapproaches.

•Forexample,respondentsfromonepilotreportedalackoftrustamongkeypartnersthatresultedinthefearofbeingpenalizedbytherelevantfederalagencyforblendingfunds(combiningfundsintooneaward),whichcausedthepilottobraid(coordinatefunds)ratherthanblendfunds.

•ChapinHallandAIRrecommendthatcollaborativesrecruitrepresentativesfromchild-servingpublicagenciestoparticipateonacross-systemsteeringcommitteetosupportandoverseethestrategicplanningandimplementationprocess.

•AIRofficialstoldusthatstatesweredelayedinbeginningtheirworkbyabout6months,inpart,becauseittooktimetogetpeopleengagedintheinitiative.

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Finding

AbsentTimeforPlanning,PartnersMayNotAchieveGoalsorUseResourcesEffectively

Stateandlocalgovernmentsandotherorganizationsmayfinditdifficulttoachievetheirgoals,includingsystemschange,iftheydonothavesufficienttimeforplanning.

•Mathematicareportedthat,3of14P3smadesystemschangeactivitiescentraltotheirapproach.Thesespecificpilotsspentyears—beforetheyappliedforP3—buildingcollaborationsacrossyouth-servingagenciestoidentifyandaddresssystems-levelissues.

•AIRofficialstoldusthatplanningentailsgettingpeopletothetable;determininginfrastructure;assessingagencies’knowledge,understanding,practices,andpolicies;andmappingresources.AIRofficialsnotedthatifasystemisnotsetupwellandtheplanningprocessisskipped,thenmoneyforservicesmaynotbeusedeffectively.

•Mathematicaconcludedthatdedicatedplanningtimecouldsupportaccomplishingfoundationalworkforsystemschange.

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Finding

Capabilities,Buy-In,andPrivacyIssuesMayHamperDataSharing

Datasharingwouldbecentraltodevelopingandimplementingperformancepartnershippilotsandtrauma-informedsystems;however,severalissues,suchasprivacyconcerns,mayunderminedatasharingefforts.

•Mathematicareportedthatthesevenpilotsthatplannedto

incorporatedatasharingintotheirP3approachwerehamperedby:

•lackofcapabilitiesamongexistinginformationsystems,

•thetimeandeffortinvolvedingettingallpartiestobuyinto

datasharing,

•agencies’desiretomaintaintheirowninformationsystems,and

•confidentialityconcerns,particularlyundertheFamily

EducationalRightsandPrivacyAct.

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Finding

Capabilities,Buy-In,andPrivacyIssuesMayHamperDataSharing,cont.

•MathematicareportedthatoneP3notedlimitedcommunicationbetweensystemdevelopersanddirect-serviceprovidersandlimiteddatamanagementexperiencemadeitdifficulttoimplementashareddatasystem.

•Mathematicaalsoreportedthatpartnersinonepilotexpressedconcernsthatashareddatasystemmightcompromisetrusttheyhadbuiltwithyouth.

•However,accordingtoAIRofficials,individualsneedtosharedataacrossagenciestopreventfamiliesfromhavingtorepeatedlyprovidethesameinformationtomultipleagencies,whichmayre-traumatizechildrenandfamilies.

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AdditionalChallenges

•Paradigmshift–GAOreportedin2019thattrauma-informedcareinvolvesaculturechangeand/orparadigm-shift.Trauma-informedpracticesmustbecomeembeddedinsystems.Developingandimplementingatrauma-informedsystemrequires,amongotherthings,trainingemployeesthroughoutandacrossofficesandorganizations.

•Leadership-AccordingtoAIRofficials,todevelopandimplementatrauma-informedcollaborativeorsystemaleaderorleadagencyhastofacilitatecross-agencycollaboration.Theleaderhastohavetimeandmoney.Inaddition,therehastobeanagencythatiswillingtoprioritizeandsustaintheeffort.

•Blendingandbraidingfunds–AccordingtoMathematica,pilots’understandingoftheflexibilitiesavailableunderP3wasimportanttotheirabilitytofullyusetheseflexibilities.Mathematicareportedthatleadersinfourofthe14pilotslackedaclearunderstandingofthedifferencebetweenblendingandbraidingfunds.

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AdditionalChallenges

•Increasedworkload–AccordingtoaformerOMBofficial,indevelopingandimplementingperformancepartnerships,officialshavetooperatetheirtraditionalprogramswhileestablishinganewinitiative,withnewpeople,andfewdollars.TheofficialnotedthatP3didnotprovidestateandlocalofficialswithrelieffromotherwork.

•Differencesinknowledgeandprogress–AccordingtoAIRofficials,agencieswanttogetsomethingoutofthecollaborativeeffort.Agenciesthatarenewtotrauma-informedcarewillgainknowledge.However,theysaidthatagencieswithmoreexperienceneedtogainsomethingtoo.AIRofficialsprovidedtrainingandtechnicalassistancetostatecollaboratives.

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