2010 SAAS National Conference and NIATx Annual Summit

1. 2010SAAS National Conference and NIATx Annual Summit Substance Abuse and Child Maltreatment: Empowering Methods for Improved Outcomes

2. What we will cover today Need for quick access to substance abuse treatment for families with co-occurring addiction and child maltreatment Kentucky�s Sobriety Treatment And Recovery Team (START) as a catalyst for change Achieving key SA and Child Welfare outcomes Lessons learned

3. 3 The Need for Empowerment Methods

4. A State and National Problem Child maltreatment and substance abuse: Kentucky & National Problem Nation/KY seeks innovation and effective models Sobriety Treatment and Recovery Teams (START) Collaboration with Substance abuse Targets young children Nationally renowned as promising practice Strong Program with Rigorous Program Evaluation

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6. 6 Kentucky START Model: A Catalyst for Change

7. START History and Sites START adapted from model developed in Cleveland in mid 1990�s with support from the Annie E. Casey Foundation. Planning for START in KY began in 2006 and has been implemented in 4 unique sites. Federal grant (ACF) awarded to KY to expand START in 2007. START is being piloted in NYC-Bronx since 2009. The START program model has been adapted and evolved to fit the needs of each system, community and the families served.

8. 8 The 5 clocks Facing Families, Providers and CPS TANF (5 year limit) Child Welfare system (15 of 22 months) Recovery Process (marked by relapse) Child development timetable (critical periods of development) Response time for staff to meet demands of the 4 other clocks

9. Status Quo: CPS and Addiction Treatment Systems CPS referrals to addiction services with little hope that clients will access the service in time or have the means to comply. Wait for family to fail so that children can be removed. Children are either in chronic risk/neglect situations or in foster care. The family�s strengths and involvement are overshadowed by the perception of addiction.

10. Status Quo: CPS and Addiction Treatment Systems CPS is focused on the child. Addiction services are focused on the adult. There is lots of tension and mistrust. The family complies or else; punitive law enforcement approach. Treatment is based on outdated concepts. Program Evaluation is external and separate from process.

11. Desired System Family has quick access to treatment and supports for retention in treatment Maximum strength of intervention � families have opportunities and persistence through relapse Families/Parents improve capacity to parent Children are safely maintained at home return home from OOHC in a timely manner

12. Desired System Child welfare, treatment providers, courts, and community partners effectively collaborate Child and adult safety, permanency, and well-being are shared desired outcomes Families collaborate and participate Strength-based and reality based SA treatment needs to be evidence-based Program evaluation is integrated as a change agent

13. Addressing the problem� Paradigm shift; New way of doing business Innovations in child welfare practices Evidence based practice in substance abuse treatment More focus needed on the specific issue of substance abuse and child maltreatment Family Centered practice Improved cross system collaboration between CPS, Courts , substance abuse providers and community

14. 14 Specific Objectives of START Child Safety: Reduce recurrence of child abuse/neglect Family stability and Self Sufficiency: Provide comprehensive support services to children and families Parental Sobriety: Provide quick, timely access to substance abuse treatment Improve treatment completion rates

15. 15 Specific Objectives of START Child Permanency: Build protective parenting capacities Increase capacity to address co-occurring substance abuse and child maltreatment Begin to change the culture within the child protection system No more �business as usual�

16. The START Model Intensive intervention model for substance abusing families in the child welfare system. START recognizes the tension between parent sobriety and child safety. START philosophy outlined in 12 Tenets agreed upon by all partners. START fosters integration among child welfare, substance abuse services, courts, community partners and sobriety supports by bridging differences in professional perspective.

17. The START Model START aims to address systems issues resulting in barriers to families accessing timely services. Family mentors engage parents early. Shared decision making philosophy. Rigorous, multi-faceted program evaluation. Long term goal of building community capacity to address co-occurring substance abuse and child maltreatment within the system and community.

18. Four Kentucky START Sites

19. 19 START: Distinctive Elements An intense and coordinated service delivery model that intervenes quickly for identified families upon receipt of CPS referral. CPS Worker and Family Mentor paired Capped caseload of 12-15 families for each CPS worker/family mentor team Quick access to substance abuse treatment-within 48 hours

20. 20 Family Mentors A family mentor is a recovering individual who: Has maintained sobriety for at least 3 years; Remains involved in active recovery support system Has had experiences that sensitize him or her to family abuse and neglect. Family mentors engage parents early in case. Family mentor transports/escorts parent to at least the first 4 treatment appointments. Family mentor provides accountability and recovery support to parents. Change the office culture and knowledge of addiction and recovery

21. 21 Family Mentors Engaging Adults

22. 22 Substance Abuse Services Strong partnership (almost a marriage) between Division of Behavioral Health (DBH) and DCBS. DBH works with substance abuse providers to improve partnership with DCBS and to increase intensity and quality of services. DBH trains DCBS staff and community partners. All participate in joint and cross training. START clients can begin substance abuse treatment within first week of initial referral to CPS. Weekly progress reports, close communication and crisis intervention in collaboration with K-START staff. Cross system data collection and sharing.

23. 23 Evaluation as an Empowerment Method

24. 24 What is Program Evaluation? Carefully collecting information about a program or an aspect of a program in order to make necessary decisions about the program and may include more than 30 research designs. START program evaluation is a quasi-experimental - Naturalistic study using large administrative data systems in both child welfare and substance abuse. Administrative data is matched across agencies and supplemented with provider collected data: START teams Substance abuse providers Kentucky Treatment Outcomes Study (KTOS) Evaluation was part of the design of the program. The Department for Community Based Services � Child Welfare � funds START including SA treatment.

25. 25 What is Empowerment Evaluation?

26. 26 Empowerment Evaluation Creates a flow of information to support mid-course corrections and continuous improvement of outcomes Evaluation is a process, not just a report Without acceptance and understanding by users as a way to change policy and to redirect resources, evaluative is a mere academic exercise Evaluation is not auditing and auditing is not evaluation. It is internal, partnership, continuous, coaching and making friends with data oriented. Empowerment evaluation is particularly important for disempowered groups.

27. 27 Guiding Principles Respect Shared Leadership (practitioner, scientist, program manager, clients/families) Embrace The Spirit Of Discovery (curiosity and passion trumps ego) Program First (keep disruption to a minimum while information is being collected: evaluation follows program) Record and Note Everything Present Findings in Graph or Chart Format Don�t Jump to Conclusions

28. 28 Challenge in EvaluationComplex Nested Models

29. 29 START Families Average age of children served is 2.9. Average age of parents is 28. 57.1% of adults have high school education. Risk factors in addition to substance abuse include income issues, domestic violence, criminal history and co-occurring mental health needs. 90% of START parents are poly-substance abusers. Drugs of abuse differ in each region.

30. 30 Steps in Analysis for Nested Datasets Descriptive statistics Code for group membership Naturally occurring groups, Groups based on sequence of events Groups based on low or high dose Comparative statistics control for case risk, age of the child, or other confounds as needed. Map into logic models Building models � logistic regression, survival analysis, SEM to examine multiple relationships. Translate back into �What does this mean for families, for children, for communities�? Present in graph or picture.

31. Major Substances Abused by Percent of START clients: Statewide (n = 330)

32. START Is Keeping Families Safe and Together

33. 33 START is Improving Parental Capacity (NCFAS)

34. START Is Persisting Toward Adult Recovery Over Time

35. START is Persisting with Men and Woman Toward Recovery

36. The Higher the Dose the More Likely the Family is Successful

37. Referral to Intake First Treatment: Woman in All SA Initiative Programs (n = 374) 37

38. Referral to Intake First Treatment: Men in All SA Initiative Programs (n = 111) 38

39. First 5 Treatments for All with first Tx A and R data needed (n = 295) 39

40. 63 newborns in START; 415 non-START newborns matched on key characteristics. 19% of START infants enter OOHC 38.8% of non-START infants enter OOHC 40 START and Cost Avoidance

41. What People Say �Despite great successes and great failures, I wish that all maltreating families would have START. I get no personal enjoyment in being punitive.� (judge) �It is easy to miss how fundamentally and profoundly helpful (immediate access to treatment) that is.� (community partner) �They (START) weren�t discriminating against us as drug abusers. They were trying to keep us together. I knew that for once I needed to finish what I started�. (father)

42. 42 Lessons Learned

43. CPS Strategies for Access and Retention Family Mentors Warm handoffs to first four appointments Family Team Meetings Reinforcing treatment recommendations with case plans and court orders Regular communication with providers Use TANF dollars to expand treatment and ensure quick access for Child Welfare clients Immediate response to relapse (safety and treatment planning)

44. Money can get you to the table, but� It doesn�t automatically make for collaboration It can�t make child welfare refer to your agency Even contractual requirements can�t work magic CPS and SA have to be meeting at the table regularly, working out differences, making changes to their own systems

45. Focus on access and retention Part of the daily conversation now Pushed treatment providers to change Intake processes Policies about use and attendance Communication with START about no-shows, relapse, and treatment participation How they welcome clients to treatment Adoption of best practices Working with clients on MAT Changing hours and intensity of program Accommodated CPS appointments and visitation

46. How we collect access and retention data for evaluation

47. Lessons about Data Collection You need to define the terms and fields very clearly Even with a data dictionary, there will still be misunderstandings about the terms You have to review the definitions periodically Be flexible about what you think you need to collect With a complicated service delivery system, you need a complicated way to obtain the data Once the data is in, people love being able to extract it themselves Program people CAN learn how to learn from their data Data entry is best done by people who enjoy it

48. The Pitfalls to Avoid Killing ourselves to get 48 hour access to all treatments Retaining clients beyond treatment efficacy Enabling clients to keep them in treatment Using the same retention efforts for clients who are in and out of treatment Being wedded to a particular level of care

49. More Pitfalls Persisting with MI techniques when a LOC change is needed Mistaking engagement for treatment progress Referring to a lower level of care than what is clinically indicated Handling disagreements between CW and SA about LOC Relying on the contract too much

50. True Confessions Only one Child Welfare staff person has been trained in NIATx so far Change leaders trained in each START site, but only 2 sites have done change projects so far No cross-system Change Teams yet

51. Even without Change Teams Providers are getting feedback from Child Welfare workers and mentors (monthly meetings and report cards) We are working hard to find placements within 48 hours of referral Programs are making positive changes to the physical environment and instituting ideas like Buddy Systems

52. The Pump is Primed We all have learned the vocabulary We collect and evaluate the data at the system level Statewide Process Improvement project I am the state �coach� for two START sites Dr. Ruth is teaching us how to look at our data without being afraid Sites are learning how to track the important elements

53. 53 Thank you and Questions