Susan H. Godley, Rh.D., Chestnut Health Systems Alison Roark, MSE, LPC, Maryhaven

1. Sustaining A-CRA Without Federal Funding: Success Stories from Outpatient and Residential Treatment ProgramsJMATE 2012 Susan H. Godley, Rh.D., Chestnut Health Systems Alison Roark, MSE, LPC, Maryhaven Mychele Kenney, MS, LCPC, Chestnut Health Systems Jennifer Smith Ramey, MS, Ed.S., Central VA Community Services

2. ACKNOWLEDGEMENTS Special thanks to Karen Krall, Randy Muck, and Jutta Butler for their work in gathering data or serving as project officers for AAFT 1 & 2 cohorts. Funding for this work has been provided by: SAMSHA/CSAT (HHSS270200700004C) AAFT 1 and 2 site staff that responded to an email sustainability survey The opinions expressed are those of the authors and do not reflect official positions of the contributing grantees’ project directors or the federal government.

3. Session Learning Objectives Attendees will be able to: 1. Define sustainment 2. Describe successful approaches for financing the sustainment of an EBT. 3. Describe successful approaches for sustaining fidelity to an EBT.

4. Definition of Sustainment/Sustainability “The ongoing operation of the infrastructure required for continued fidelity and sustainability (e.g., continual training, supervision and coaching, fidelity measures, and outcome data collection).” (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005, p. 73-74)

5. How would A-CRA sustainability be assessed? • Do current staff have adequate clinical knowledge about A-CRA? • Are planned # of sessions at or above the minimum (could be combination of individual/group)? • Are certified clinicians delivering A-CRA? • A certified A-CRA supervisor? • At least bi-weekly supervision that covers critical supervision components? • Does supervision include reviews of recorded sessions? • Is there a training process that includes components requirements required during implementation? • Is there a clinical certification process that mirrors one used during implementation?

6. Data from Prior Cohorts Plans for sustainment (33 sites): • 28 (85%) of the sites reported they had plans to sustain A-CRA after federal grant funds ended. • 23 (82%) of those sustaining had a trained/certified/or almost certified supervisor at the end of the grant period. • 25 (89%) of those sustaining had at least one certified clinician at the end of the grant period. • 19 (68%) of those who planned to sustain said they had plans for regular supervision • 12 of the above (63%) had plans to review recorded therapy sessions to some degree

7. Sources of Funding for Sustainment • 16 (48%) had a combination including new federal grants (6), private insurance, Medicaid, drug court/probation • 3 (9%) reported sustaining with funds for serving those with dual diagnoses • 2 (6%) were sustaining with a new fed grant only • 1 (3%) were sustaining with a foundation grant only • 1( 3%) were sustaining with state funding only • 5 (15%) said they were sustaining, but did not specify a funding source

8. Facilitators 1 or more sources of funding (23) Found treatment effective/helpful/useful/had positive experience (11) Has trained/certified staff with valuable skills/certified supervisor (8) Other (4) Barriers State Medicaid plan/county does not reimburse for substance use tx/or only group tx (4) Attrition/turnover (3) Difficulty in getting reimbursed for supervision or other aspects of training (2) Other (5) Facilitators & Barriers

9. Sustaining A-CRA Through Change: An Outpatient Treatment Approach Alison Roark, MSE, LPC A-CRA/ACC Supervisor Maryhaven Columbus, OH

10. Program and Target Population Maryhaven is a not-for-profit agency which provides integrated behavioral healthcare services, with a specialization in addiction recovery care to adults and children suffering from addictions and mental illness. The adolescent outpatient department offers three evidence based programs: A-CRA, MDFT, and ACC. All programs serve youth ages 12-18 and their families. Primary referral source are Franklin County Children’s Services and the Franklin County Juvenile Court System.

11. Funding/Impetus for Implementation and Implementation Experience Maryhaven was a part of the AAFT2 (Assertive Adolescent and Family Treatment) and received funding from the Alcohol, Drug, and Mental Health Board in Columbus. The grant period was 10/1/07 to 3/31/11 and enabled Maryhaven to implement community-based ACC for youth leaving our residential program. Maryhaven also provides IOP groups for court-referred youth; clinicians worked in both programs and therefore were trained in A-CRA and began using A-CRA procedures and techniques with groups and individuals.

12. Factors Related to Decision to Sustain Prior outcome data for IOP groups was poor and Juvenile Court asked us to overhaul the program; we stopped running groups and began A-CRA community based services in March of 2010. Since then, outcomes have improved greatly. Most recent data suggests a success rate of between 65 and 70%. In 2009, Children’s services released an RFP for residential aftercare emphasizing evidenced based programs. We submitted an RFP based on ACRA/ACC, which we had already implemented through AAFT. Children’s services accepted our proposal and we were able to expand our aftercare program beginning in January of 2010.

13. Finances and Marketing Efforts Since AAFT ended, all referrals come directly from court or children’s services. If client is Medicaid eligible, Medicaid is billed for services. If not, referral source is responsible for payment. There are some consultation services which are not Medicaid eligible and are always paid directly by the referral source. We do not currently accept any private insurance as payment. We market to our referral sources and this includes attending provider fairs and staff meetings to inform probation officers and caseworkers of services.

14. Maintaining Fidelity and Training New Staff After Turnover Original providers were trained by Chestnut via AAFT. In September 2010, we purchased additional training from Chestnut to train a new clinician and supervisor. Since then, all training and certification has been done on site by certified A-CRA supervisor. Training agendas are approved by Chestnut. The supervisor conducts monthly fidelity checks by listening to and rating DSRs for each clinician. Supervision occurs on a weekly basis for case review. We have maintained our relationship with Chestnut in order to further ensure fidelity to the model. To date, all clinicians have received final A-CRA certification through Chestnut.

15. External and Internal Supports Champions of the model include previous and current supervisors. Administration is also very supportive of evidenced based treatments. We strive to maintain good relationships with referral sources on both an administrative and clinical level. Clinicians work very closely with probation officers and caseworkers to provide the best possible care to the clients. It is a true collaboration between all involved parties.

16. Recommendations for Provider Organizations and Policymakers Relationship with referral and funding sources are key! Keep an open dialogue and be willing to compromise. Use outcome data and studies promoting evidence based practices if possible. Team mentality. Help clinicians to feel supported and work together to provide best possible care to clients. Champion the model. If you believe in it, others will too!

17. Committing to Evidence-Based Programming in a Residential Setting Mychele Kenney, MS, LCPC Director of Youth Services Chestnut Health Systems Bloomington, IL

18. Program and Target Population Chestnut Health Systems is a not-for-profit behavioral healthcare facility. Our core service areas are addiction, mental health, applied research and training, and employee assistance/workplace services. Our youth program serves ages 13-18 in two locations, Central Illinois (Bloomington) and Metro-East St. Louis (Maryville). Our clients range from rural to urban, 60% male, 72% Caucasian, 76% involved in criminal justice system. We provide school-based early intervention services, OP, IOP, and residential levels of care, as well a recovery home in our Bloomington location for youth.

19. Funding/Impetus for Implementation and Implementation Experience Engagement and retention issues arose in our Bloomington young women’s residential unit. We were aware of A-CRA because of the Cannabis Youth Treatment (CYT) and Assertive Continuing Care (ACC) randomized clinical trial studies, and knew our research and training division was involved in training in the model. We decided to implement with no set-aside funding specific to this project.

20. Factors Related to Decision to Sustain We always planned to implement and sustain. Regional Manager bought into plan for program improvement and resource commitment of existing staff. We proceeded with implementation/sustainability plans slowly, introducing A-CRA to residential units one at a time. We recognized the impact that the model was having on our first unit (Blm. Girls unit) and the improvements in retention, as well as the confidence in our line staff.

21. Finances and Marketing Efforts Our use of A-CRA is included in all of our marketing materials. Have received praise/reinforcement from our state licensure/funders as well as from Joint Commission. Our services are primarily paid by Medicaid and Insurance. We have some state funding available for indigent clients. Have been able to secure funding for additional programming with Juvenile Court Services to provide A-CRA to high-risk youth in their homes.

22. Maintaining Fidelity and Training New Staff After Turnover Started out slow and gradually spread the intervention (currently have all units using A-CRA after 6 years). Planning for available supervision and rating is key. Sent staff to Chestnut A-CRA training when possible, but developed our own internal training. Trained all supervisors and additional raters (8 certified supervisors, two additional “raters” currently). Built recording and certification expectations into both job descriptions and policy. Continuous A-CRA trainings are offered (both individually and group/inservice). Provide Quality Improvement measures and feedback to staff regarding how they are doing on the certification/fidelity process.

23. External and Internal Supports Commitment from CEO and Regional Manager to support Youth Director. “Cheerleaders” – not always chosen from the “obvious” fits. Chestnut’s Lighthouse Institute – training, consultation and ongoing support/encouragement. Joint Commission & State Licensing agent (DASA).

24. Recommendations for Provider Organizations and Policymakers Plan, plan, plan (understand what you are committing to and what it will mean to your program) Coach, coach, coach (use your cheerleaders and existing staff to mentor, encourage and keep the spirit alive; make sure you can stay on top of fidelity) Integrate, integrate, integrate (the more you can incorporate A-CRA into all of your programming, the better – groups, bulletin boards, treatment planning, family programming)

25. Life After Our Grant: Sustaining (and Spreading!) A-CRA Jennifer Smith Ramey, MS, Ed.S. Program Manager Central Virginia Community Services, Lynchburg, VA Elizabeth McGarvey, Ed.D. Associate Professor of Public Health Sciences University of Virginia, Charlottesville, VA

26. Program and Target Population Central Virginia Community Services is behavioral healthcare organization, providing substance abuse, mental health, and intellectual disability services Youth ages 12-18 with a substance use disorder Assessment, outpatient therapy, case management, crisis intervention

27. Funding/Impetus for Implementation and Implementation Experience In 2004, we received a SAMHSA Targeted Capacity Expansion (TCE) grant through the Center for Substance Abuse Treatment Our 2nd SAMHSA TCE grant to deliver evidence-based services for youth with SUD We targeted two areas (urban city/Lynchburg and rural county/Amherst County)

28. Factors Related to Decision to Sustain Outcome data Client, clinician satisfaction with the program Flexibility of the treatment model Relationship with our stakeholders Model well-suited to address co-occurring disorders

29. Finances and Marketing Efforts Medicaid/insurance reimbursement Community-based funding Communication with stakeholders, agency administrators Sharing outcome data Newsletters, tv/media outlets

30. Video

31. Maintaining Fidelity and Training New Staff After Turnover Local certified supervisor All staff on co-occurring team trained in model In-house training of staff in other departments Mentoring new staff, interns Random fidelity checks, case staffings, review of progress notes

32. External and Internal Supports Top-down, bottom-up agency support “Champion” or “Cheerleader” Juvenile and Domestic Court judges, probation officers Department of Social Services Alternative schools Truancy officers

33. Recommendations for Provider Organizations and Policymakers Communication with key stakeholders Use of outcome data Enthusiastic, flexible staff Willingness to think outside the box

34. Contact Us • Susan Godley, sgodley@chestnut.org • Alison Roark, aroark@maryhaven.com • Mychele Kenney, mkenney@chestnut.org • Jennifer Smith Ramey, Jennifer.Smith.Ramey@cvcsb.org