CANS Implementation: A Brief Overview of Resources and Processes
Goal
The primary goal of CANS implementation is to help children and families. CANS implementation works to empower persons at every level of the system to collaboratively identify and address the most important needs facing children and families, and to capitalize on their strengths. CANS implementation is used as an aid to decision-making for persons at every level of the system. Persons in each part of the system must be equipped to utilize the CANS as a tool for communication and action. The implementation supports provided on this wiki are explicitly designed to assist you in accomplishing the task of facilitating this transformation to unified, client and family-directed communication and action. Many of these supports have been developed to help families and providers involved in San Francisco's public behavioral health system to collaboratively identify needs and strengths, and work collaboratively to meet goals related to those needs and strengths.
Beginning on the next page (CANS Parent and Caregiver Resources), we lay out the resources available through this toolkit by whom the resources are targeted to empower, beginning with parents and families. We provide a brief overview of each resource on each page. The full resource is included as an attachment, whenever possible. Throughout this website we also provide outside links to examples of other systems and resources and the work they are doing in using the CANS as a tool to help children and families. Where we can, we also provide instantly accessible attachments highlighting relevant aspects of the work of these other persons in their respective systems. If there is any problem accessing a site or attachment, please feel free to contact me at: ndisrael@gmail.com and I will be happy to investigate what's happening and find a way to connect you to the resource of interest. Thanks for your dedication to children, youth and families!


Implementation principles / Lessons learned
1. Leadership buy-in is essential. Commitment from the top signals that all others should approach this effort with an eye to making it work. Ambivalence from the top signals that it’s okay to let barriers to implementation prevent success. There will be challenges with the implementation of any new practice. No matter how well conceived or executed, implementation of new behavior is often anxiety provoking and uncomfortable for all who have to change their behavior. Implementation research indicates that about 15% of a population is willing to try out a new practice. Another 15% will strongly resist innovation. Ambivalence from leadership signals to resistors that they can dominate the conversation and derail implementation for everyone. Strong support from leadership signals to early adopters of an innovation that they can get excited about their new experience; they can then influence the next wave of adopters to give the new practice a try.

2. Begin with the willing. It is important to begin pilot implementation with persons and agencies motivated to try a new initiative such as the CANS implementation. Take the time to sit down with agency representatives to figure out what they are willing to commit to, and how the CANS could help them reach service process or outcome goals which are meaningful to their program. Here in San Francisco the CANS was first implemented in a pilot effort designed to reduce assessment wait time, and increase the understandability of behavioral health recommendations made, for clients of the child protective service system. Starting with this agency gave us a clear goal and a willing partner with which to begin implementation.
Often times, agencies or organizations willing to try a new initiative have a history of trying new initiatives. Staff may be used to trying new clinical practices, and may have the desire to learn how to use a new tool and new approach to service delivery. Staff at organizations who have a history of successfully implementing new practices are also likely accustomed to the adjustments that have to be made as a new practice is being implemented in their specific context. Beginning with wiling programs whose staff understand the investment and potential benefits of using the tool positions your implementation effort for success.
When you do have success in achieving any of the desired outcomes in using the CANS (reduced wait time, reduced attrition, easier communication of client needs / strengths, better clinical or functional outcomes), you can use that to demonstrate the usefulness of the tool to other agencies and system partners whom you’ll be looking to bring on board in the future.

3. Build on the CANS as a communication and thinking tool. When we see a new form there are a couple of instant ideas we have about it. The first is that it might be something that we can have someone else fill out, and then we can use it for one purpose or another; we don’t have to actively engage in the process of completing it. Another is that completion of the form will produce a decision for us.
The CANS is an anti-form. It is explicitly designed for people to use it as an opportunity to integrate and communicate information from multiple sources. Rather than being a passive instrument for a single informant to complete, it is a tool that prompts the clinician to gather and integrate information from multiple sources in forming and justifying a rating. Based on the ratings made, the clinician has a defined set of needs requiring intervention, and strengths for use or development. The specific supports used to address those needs are decided by the clinician in concert with the family, available practice guidelines, and clinician knowledge of available services.
This approach makes many clinicians both happy and uncomfortable. Because the CANS is a thinking tool, it is not prescriptive. It allows for clinicians to use their experience and expertise in integrating information and making treatment decisions. Yet clinicians sometimes need more structure to the process to get the most out of it. Here are three ways we’ve found to maximize the return on this process:

a. Connect the CANS to what families want. Families, when they hear of the CANS as a tool designed to make communication more transparent, are often elated. Families routinely are bombarded with and bewildered by various assessments. Explaining the CANS’ very understandable scoring system immediately reduces the anxiety surrounding assessment.
The CANS also offers parents the opportunity for empowerment in the assessment, treatment planning, and treatment review processes. Gathering information to rate CANS items can take place in the order families prefer. When clinicians explain that all the information for the CANS has to be gathered, but that we can start by talking about whatever families’ prefer-- Strengths or Needs—families are often happily surprised. When families are present with a summary of the assessment in their words, with a focus on what they have said which justifies a rating of a ‘2’ or a ‘3’ on a CANS item (meaning it must be addressed), they are prepared for the Treatment Planning process. And when they are empowered to call a review of how Treatment is progressing in addressing those ‘2’s and ‘3’s families are more likely to see the connection between the effort they invest in treatment and achieving the goals they have set.
Finally, parents are often devalued as experts. Yet they have the most experience observing how their family functions in various contexts. Eliciting that information and collaborating with the entire family throughout treatment is critical to the family reaching their wellness goals. Having families teach clinicians how to use the CANS in ways that facilitate eliciting important information and creating a collaborative treatment process is an experience that empowers families and insures that the CANS is immediately and continuously applicable to the work clinicians engage in with families.

b. Connect the CANS to decisions clinicians have to make. Clinicians are confronted with difficult decisions at all critical points in the clinical process: assessment, treatment planning, treatment delivery, and closing. The CANS offers a way to connect each of these processes in a way that builds trust and collaboration with families. The communication structure embedded in the CANS and made explicit by families themselves in the parent-led training facilitates the accurate identification of concerns which are most pressing to a family. Using a collaborative approach, treatment plan goals can be constructed together to address those needs. In our parent-led CANS training we describe a specific family-identified process by which clinicians can engage families in the process of constructing realistic, achievable goals. We also review how to engage the family in a review of treatment progress during the course of treatment.
Thus at each key point in the clinical process, clinicians can use the CANS to maximize the likelihood that the decisions made are viewed as collaborative and family-driven.

c. Connect the CANS to decision-making needs of administrators. Administrators rarely have the opportunity to have a birds-eye view of how the system meets client needs. System-wide use of the CANS allows such a view to be created via simple reports. These reports can be built such that administrators can drill down to any level of the system to see how families’ needs are met and their strengths are developed. Administrators are not only beset by requests to describe what is and is not working for clients system-wide, they often must describe various subpopulations of the system. Quickly generating descriptions of subpopulations is a straightforward task for data analysts. Because the CANS includes ratings of a wide variety of clinical, functional, and contextual information, in-depth profiles can be generated for a wide variety of client sub-groups.
CANS data and algorithms can also be employed in situations requiring especially thoughtful consideration and risk management. Completing a structured case review improves the chances that high-profile clients are provided the appropriate type and intensity of supports. Included in this toolkit is a CANS-based tool specifically for use in understanding the progress and treatment needs of such high-profile clients. Using this tool and others like it, administrators can better understand the needs of different populations served within the system, and reduce the likelihood of ineffective or iatrogenic care occurring to clients.

4. Engage with persons who complain. People who complain about the implementation process often provide valuable information about what could be improved. Though many people are willing to tolerate some discomfort in implementation of a new practice, this willingness is time- and effort-limited. People who complain often let you know which changes to the implementation would result in greater buy-in. You must be able to always keep your desired outcome of using the CANS in mind in addressing these complaints.

Requests to shorten the CANS by removing items or domains must be considered in the light of what will be lost in your ability to improve client context, symptoms, and functioning. These requests should only be granted if there is a very clear rationale for an item or domain’s exclusion. Such changes often come at a very serious cost to your ability to move the system towards transparency and accountability. Requests to make an electronic health record system more user-friendly, or to make a printout of the assessment more readable, however, would need to be solved as expediently as possible.

5. Amplify the voices of the successful. Implementation generates a chorus of competing narratives about the effort and its effects. Highlighting successes sends several messages. First, it sends a clear positive message to persons who have expended the effort and creativity needed to make this new practice useful for families. Second, it often reminds people to be open to the possibility that there are advantages to implementation that they may not have considered or yet experienced. Finally, it provides a cost-free way of rewarding particularly hard-working staff. In a field in which there are often profound challenges to success, echoing a message of success can uplift and remoralize clinicians who have taken an additional risk and invested additional effort in their work with families.

Additional detail on our implementation process and strategies is provided in the White Paper below.