An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center

Transcription

1 COMMISSIONED BY THE DC DEPARTMENT OF YOUTH REHABILITATIVE SERVICES An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center Kimberly Jeffries Leonard, Ph.D. April 2012

2 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center ii TABLE OF CONTENTS Executive Summary Background Method/Approach Summary of Key Findings Recommendations 1.0 Introduction Assessment Background Assessment Objectives Assessment Methodology/Approach 2 2 New Beginnings Structural Overview 3 3 The Analysis Program Organizational Design Treatment Program Design Youth Assessment Policy and Procedures Staffing for Treatment Services Quality Improvement Efforts 22 4 Review of Drug and Alcohol Infiltration 24 5 Conclusion 27 6 References 27 7 Appendices List of Key Informants Interviewed Dates of On-site Visits and Interviews List of Documents Reviewed Credentials of Independent Consultant iii iii iv iv v

3 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center iii Executive Summary Background The Department of Youth Rehabilitation Services (DYRS), at the direction of the District of Columbia City Council (DC Council), engaged an independent consultant to conduct an assessment of New Beginnings Youth Development Center (New Beginnings) to review its organizational and operational structure, substance abuse treatment approach, its strengths and weaknesses, and its capacity to provide adequate substance abuse treatment services required to address the treatment needs of the New Beginnings population. Moreover, the assessment was specifically designed to address the following: 1) The need for intensive, evidence-based substance abuse and alcohol treatment, recovery and relapse prevention programs at New Beginnings; and 2) The examination of reporting of confiscation of drugs and alcohol found on the grounds of New Beginnings. In order to address the substance abuse and alcohol treatment objective delineated by the DC City Council, a comprehensive review of New Beginnings organizational and operational structure, treatment models and programming was conducted through the analysis of six broad areas of consideration and related questions specific to each area: Treatment Program Design Is the current treatment design adequate to meet the needs of the youth in the context of the current structure of the facility s overall model? Program Organizational Design Has substance abuse and alcohol treatment been implemented with fidelity at the facility as originally intended or designed? Have challenges been identified and resolved to ensure successful implementation of the program? Youth Assessment Are youth adequately assessed to determine their substance abuse and alcohol treatment needs? How are needs assessments utilized to inform the development and implementation of a treatment plan and, subsequently, individualized treatment and service delivery for the youth? Policy and Procedures Are policies and procedures established and operationalized to adequately delineate the process for assessing the youths substance abuse needs, to triage to appropriate care based on the youths identified needs and monitoring the youths treatment progress? Are policies and procedures established to identify the treatment program model components and criteria for implementation, criteria of any staff implementing the program including required qualifications and training requirements and whether the policies and procedures address how the substance treatment program fits into the overall organization and operations of the facility?

4 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center iv Staffing for Treatment Services Are treatment services provided by adequately trained staff who understand the treatment model being implemented and have a broad understanding of behavioral health issues, in particular substance abuse? Quality Improvement Efforts Are current efforts in place to review and improve the current substance abuse treatment process, including implementation and staffing? The second objective of this assessment was to thoroughly examine the reports of confiscation of drugs and alcohol (contraband) found on the grounds of New Beginnings. While the goal of this examination was not specific, the review was conducted with a two-fold purpose: 1) To determine the extent and magnitude of drug and alcohol confiscation within New Beginnings; and 2) To determine whether additional or modifications to existing protocols need to be implemented to address drug infiltration into the facility. Method/Approach The consultant employed a variety of qualitative data collection methods to address the assessment objectives. They included the following: 1) conducted interviews with key informants; 2) gathered and reviewed relevant policy and procedure documentation and reports related to the functioning and structure of New Beginnings; 3) performed site visits and process walk-throughs; 4) conducted literature reviews examining relevant program models being implemented at the facility; and 5) facilitated follow-up interviews, as necessary. Content analysis was performed on the qualitative data to identify significant themes and issues. The assessment findings, including program challenges and recommendations are summarized in this report. Summary of Key Findings During the process of conducting this assessment, several themes emerged as indicators of the challenges of implementing effective substance abuse treatment for those youth in need at New Beginnings. These themes included: 1) the majority of the youth within New Beginnings show evidence of some type of substance abuse issue, however the lack of a standardized assessment process does not allow for the youth to be assessed properly nor receive the appropriate level of treatment; 2) there is a lack of alignment between the foundation of the DC Model, upon which the programming of New Beginnings is based, and the tenets of the Seven Challenges substance abuse treatment program, resulting in a treatment model that has historically been challenging to integrate into facility programming; 3) there is a lack of communication between key operational units at New Beginnings which leads to a deficiency in understanding of policies and procedures whose implementation is critical to programmatic success; 4) YDR staff do not have the required background or experience to lead substance abuse treatment groups at New Beginnings; and 5) the disconnect amongst the staff between having a rehabilitative (positive youth development) approach with the youth versus a correctional approach with the youth must be addressed.

5 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center v Despite these barriers to implementation, all stakeholders interviewed seemed very open to making the necessary adjustments needed to facilitate an effective substance abuse treatment program within New Beginnings. They were positive that the current challenges could be overcome and were willing to commit to working with the DYRS leadership to affect the appropriate systematic, operational, and cultural changes that would ensure the success of the program. A number of changes have been put in place which infers support to the commitment expressed by these stakeholders. Recommendations In light of the findings described above, five key recommendations were identified. These recommendations provide the framework for structuring a substance abuse continuum of care at New Beginnings that can be evaluated on process and outcome measures to determine if the program is meeting the needs of those youth with substance abuse issues. Implementing these recommendations and monitoring the execution of the process will assist New Beginnings in achieving those results expected by the leadership at DYRS and those the Agency serves. 1. The Seven Challenges substance abuse treatment program currently implemented at New Beginnings should be replaced by a substance abuse treatment program that is more adaptable to the foundations of the DC Model. In its current implementation, it cannot be determined if in fact Seven Challenges has been effective for the youth at New Beginnings. However, these implementation challenges are longstanding and point to the need to choose a new program better suited to New Beginnings. An expert panel of internal and external stakeholders should be charged with finding a new model. The members of the workgroup should consist of members of the DYRS Behavioral Health Unit, New Beginnings leadership and a substance abuse subject matter expert. This workgroup should be charged with evaluating the Agency s needs and available substance abuse treatment models to identify a program that will work in concert with the DC Model program. 2. A process to assess all youth entering New Beginnings for substance abuse issues (including nicotine addiction) should be developed by DYRS and implemented in order to determine the level of treatment needed by each youth. DYRS has initiated this process by having four staff trained on conduct of the Global Assessment of Individual Needs Initial and has implemented the policy of having all youth newly admitted to New Beginnings assessed. Four additional staff is scheduled to be trained in July, The protocol should include identifying cigarette smokers via self-report and administration of the Modified Fagerström Tolerance Questionnaire (mftq) to these youth. 3. DYRS should create an environment conducive to high-quality substance abuse treatment, and identify and empower an implementation team to oversee the all

6 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center vi aspects of a substance abuse continuum of care including the youth assessment process and any new models introduced. Integral to this type of environment is the identification and implementation of a substance abuse treatment program whose model is consistent or adaptable to the DC Model upon which New Beginnings programming is based. The substance abuse program model should have in place opportunities for staff to receive technical assistance which would include implementation advice, guidance, and coaching for all staff involved in the conduct of the program. A substance abuse subject matter expert or expert with the selected model should be retained to assist with implementation. All staff at New Beginnings should be fully oriented on any substance abuse treatment program implemented and as appropriate, training for non-clinical facility staff. New Beginnings should implement a comprehensive continuum of substance abuse care that includes prevention, education, and intervention programming and smoking cessation. This prevention and educational intervention should be developed and required for all youth who do not require formal substance abuse treatment. Behavioral Health staff should head the implementation team for the continuum of care and should be given the authority to ensure that all substance abuse treatment protocols, prevention, intervention, and smoking cessation programs are implemented appropriately and with fidelity. It is the recommendation of this consultant that Behavioral Health staff implement all clinical aspects of the substance abuse treatment program and related substance abuse programming under the continuum of care, with the New Beginnings facility staff, i.e. Youth Development Representatives (YDRs) and others, supporting and complementing the delivery of the substance abuse treatment program and other aspects of the continuum. 4. An evaluation of the substance abuse treatment program should be conducted by DYRS, through the use on an external evaluator. This information should be used to determine the effectiveness of the program, program enhancements to be implemented if needed, and if the program should continue to be implemented based on the outcomes. If an evaluation process is not provided by the program, a process and outcome evaluation should be developed by the external evaluator prior to substance abuse services commencing. 5. DYRS should create an internal Continuous Quality Improvement (CQI) process to monitor the functioning of the substance abuse treatment program and the continuum of substance abuse care within New Beginnings. The CQI process should define and measure key processes, outputs and outcomes associated with the substance abuse program. In addition, a feedback loop by which these findings can be regularly shared and acted upon should be developed, implemented, and monitored for efficacy. The DYRS leadership should review CQI findings quarterly to assess the progress of the substance abuse treatment programming.

7 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center vii Since the inception of this project, a number of improvement initiatives have either been put in place or foundation for improvements have been laid. These improvements speak directly to a number of the recommendations made in this report. These improvements include triaging only those participants in need of substance abuse treatment into treatment groups; and increasing the capacity of internal staff to conduct GAIN-I assessments by training staff, and developing and implementing an assessment process for new admitted and newly placed youth.

8 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center Introduction 1.1. Assessment Background. The Department of Youth Rehabilitation Services (DYRS), at the direction of the District of Columbia City Council (DC Council), engaged an independent consultant to conduct an assessment of New Beginnings Youth Development Center (New Beginnings) to review its organizational and operational structure, substance abuse treatment approach, its strengths and weaknesses, and its capacity to provide adequate substance abuse treatment services required to address the treatment needs of the New Beginnings population. Moreover, the assessment was specifically designed to address the following: 1) The need for intensive, evidence-based substance abuse and alcohol treatment, recovery and relapse prevention programs at New Beginnings; and 2) The examination of reporting of confiscation of drugs and alcohol found on the grounds of New Beginnings Assessment Objectives. To address the first substance abuse and alcohol treatment objective delineated by the DC City Council, a comprehensive review of New Beginnings organizational and operational structure, treatment models and programming was conducted. Six broad areas of consideration were identified through which this assessment was conducted. The six identified areas and related questions guiding this objective are described below. Treatment Program Design Is the current treatment design adequate to meet the needs of the youth in the context of the current structure of the facility s overall model? Program Organizational Design Has substance abuse and alcohol treatment been implemented with fidelity at the facility as originally intended or designed? Have challenges been identified and resolved to ensure successful implementation of the program? Youth Assessment Are youth adequately assessed to determine their substance abuse and alcohol treatment needs? How is needs assessment utilized to inform the development and implementation of a treatment plan and, subsequently, individualized treatment and service delivery for the youth? Policy and Procedures Are policies and procedures established and operationalized to adequately delineate the process for assessing the youths substance abuse needs, to triage to appropriate care based on the youths identified needs and monitoring the youths treatment progress? Are policies and procedures established to identify the treatment program model components and criteria for implementation, criteria of any staff implementing the program including required qualifications and training requirements and whether the policies and procedures speak to how the substance treatment program fits into the overall organization and operations of the facility?

9 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center 2 Staffing for Treatment Services Are treatment services provided by adequately trained staff who understand the treatment model being implemented and have a broad understanding of behavioral health issues, in particular substance abuse? Quality Improvement Efforts Are current efforts in place to review and improve the current substance abuse treatment process, including implementation and staffing? The second objective of this assessment was to thoroughly examine the reports of confiscation of drugs and alcohol found on the grounds of New Beginnings. While the goal of this examination was not specific, the review was conducted with a two-fold purpose: 1) To determine the extent and magnitude of drug and alcohol confiscation within New Beginnings; and 2) To determine whether additional or modifications to existing protocols need to be implemented to address drug infiltration into the facility Assessment Approach/Methodology. The consultant employed a variety of qualitative data collection methods to address the assessment objectives. They included the following: conducted interviews with key informants; gathered and reviewed relevant policy and procedure documentation and reports related to the functioning and structure of New Beginnings; performed site visits and process walk-throughs; conducted literature reviews examining relevant program models being implemented at the facility; and facilitated followup interviews, as necessary. Content analysis was performed on the qualitative data to identify significant themes and issues. The assessment findings, including program challenges and recommendations are summarized in this report.

10 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center New Beginnings Youth Development Center Overview The DYRS mission is to improve public safety and give court-involved youth the opportunity to become more productive citizens by building on the strengths of youth and their families in the least restrictive, most homelike environment consistent with public safety. Similarly, its shared vision with DYRS is to provide the nation s best continuum of care for court-involved youth and their families through a wide range of programs that emphasize individual strengths, personal accountability, public safety, skill development, family involvement and community support. Through New Beginnings programming, they support this mission. New Beginnings, a 60-bed, secure facility for committed male youth, opened on May 29, 2009 as a key element of the District s juvenile justice reform initiative. The facility is located in Laurel, Maryland on the grounds of the former Oak Hill facility. New Beginnings provides 24-hour supervision, custody and care, including residential, nutritional, educational, recreational, medical, dental, workforce development, substance abuse and mental health services. The facility s 9-to 12 month behavior modification program, modeled after the acclaimed Missouri approach, serves the youthful offenders with the highest risk. The goal of the New Beginnings program is to prepare youth for successful community reintegration while minimizing their risk for re-arrest and re-offense. This is done through an approach that uses the principles of Positive Youth Development and guided peer interaction to promote such a transformation. During the course of their stay, the youth are expected to progress through six levels of development. Each of these activities is conducted and monitored by Youth Development Representatives assigned to the units and is supported by JJIC s behavioral health staff, unit management and educational/ recreational teams.

11 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center Analysis This report section presents the analysis of New Beginning s organizational and operational policies and procedures across the six key areas identified by the consultant as critical to successful implementation of an effective substance abuse treatment program. The results of the analysis are presented for each critical area in tandem in the following manner: 1) delineation of the relevant assessment questions; 2) description of the observational findings; 3) discussion of the observational findings; and 4) recommendations for programmatic improvement and delineation of relevant action items for next steps. 3.1 Critical Area 1.Treatment Program Design Is the current treatment design adequate to meet the needs of the youth in the context of the current structure of correctional facility s overall model? Observations - The Seven Challenges is the substance abuse treatment model currently being implemented in New Beginnings. This program is recognized in the Substance Abuse Mental Health Services Administration s National Registry of Evidence-Based Programs and Practices and has been shown to be effectively implemented in a number of settings, including public and private juvenile justice facilities and settings. It is a holistic approach to adolescent substance abuse treatment that not only addresses drug use but the reasons for using. It is based on a harm reduction model and incorporates cognitive, emotional, and health decision making processes that promote self-efficacy by encouraging clients to think for themselves and make their own informed decisions. The Seven Challenges program offers youth the opportunity to think about making changes in their lives. There is a strong emphasis on teaching social, psychological, and emotional life skills that enable clients to learn new adaptive ways to cope with their stressors and meet their needs. Through individual therapy, group therapy, and journaling clients have the opportunity to learn skills and develop resources in areas such as problem solving, communication, anger management, social/relational, selfcontrol, thinking, relaxation, and stress reduction. During implementation, there is no preset, manualized process for the sessions, but rather the counselor and client identify the most important issues at that moment and discuss these issues while the counselor seamlessly integrates The Seven Challenges into the conversation. The challenges include: (1) talking honestly about themselves and about alcohol and other drugs; (2) looking at what they like about alcohol and other drugs and why they are using them; (3) looking at the impact of drugs and alcohol on their lives; (4) looking at their responsibility and the responsibility of others for their problems; (5) thinking about where they are headed, where they want to go, and what they want to accomplish; (6) making thoughtful decisions about their lives and their use of alcohol and other drugs; and (7) following through on those decisions. The Seven Challenges reader, a book of experiences told from the perspective of adolescents who have been successful in overcoming problems, is used by clients to generate ideas and inspiration related to their own lives. In addition to participating in counseling sessions, youth write in a set of nine

12 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center 5 Seven Challenges Journals, and counselors and youth engage in a written process called cooperative journaling. The program is flexible and can be implemented in an array of settings, including inpatient, outpatient, home-based, juvenile justice, day treatment, and school. The number, length, and frequency of sessions depend on the setting. Counselors with various levels of experience in working with mental health and substance abuse problems are trained in program implementation. However, the success of the program is dependent upon the skill and engagement of the counselor. Several excerpts below from The Seven Challenges Manual highlight the importance of this type of expertise in order for the model to be impactful to the client. From The Seven Challenges Manual: To successfully implement the program, staff must be thoroughly familiar with The Seven Challenges published material; know how to introduce the program and the materials to youth; know how to give feedback to youth who write in the journals; know how to promote openness and talk with, or counsel, young people to empower them, without eliciting defensiveness and without getting hooked into power struggles; and be able to integrate the topics or content of counseling sessions with The Seven Challenges process. They must be prepared to work in a holistic manner with youth. On the one hand, this means being informed by a basic understanding of drug information (widely available elsewhere; not included in this manual). On the other hand, this means being able to teach problem solving skills and various life skills, which are also essential to this program. The extent to which the full power of this program is utilized will depend to a large extent on the clinical skills of those who use it. Good drug counseling must be responsive to the interests and needs of youth, and their current realities. Effectiveness is seriously compromised in pre-scripted, one-size-fits-all programs. Therefore, counselors must plan sessions according to the needs of individual clients at any given time. Although not prescripted, the content of each and every counseling session should be integrated in such a way that young people can see how their efforts relate to helping them through the decision making process using The Seven Challenges Process. Counselors provide leadership at counseling sessions by pursuing discussions on important issues relevant to youth or initiating activities that promote thinking about relevant issues, or by teaching important life skills. This requires awareness of which issues to focus on and when. It requires attentiveness to individual or group needs, and responsiveness to youth concerns. Co-occurring problems need to be addressed in counseling sessions. Some counselors with a background in drug counseling do not feel

13 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center 6 prepared to help with mental health issues. The program materials help with this. But these counselors may want to broaden their own training, or work on teams with other counselors with a broader background in mental health. Based on information received in key informant interviews, the model was selected because the DYRS leadership at the time structured an in-house Behavioral Health Unit that would be responsible for substance abuse treatment. This allowed for the identification and implementation of a substance abuse treatment program that could be run by DYRS staff and integrated into the secured facility. Seven Challenges was identified and chosen as the treatment model for New Beginnings based on a number of factors: 1) it was an adolescentbased program; 2) it was an evidence-based program; and 3) allowed for the opportunity to build the capacity from within New Beginnings to address substance abuse issues in the youth. At the time of implementation of the treatment model, the DC Model was also being adapted for implementation within New Beginnings as the basis for juvenile justice committed youth rehabilitation. The DC Model used the Missouri Model as a basis for its structure. The Seven Challenges treatment program had to be adapted to fit within the structure of the adapted Missouri Model which emphasized a group-based approach to all programming. After a number of trainings for the staff and intensive technical assistance by The Seven Challenges contractor to help adapt the treatment model to fit within the DC Model, it was decided that each unit would engage in two group sessions per week to address substance abuse needs with all members of the unit participating in the groups. Individual treatment needs would be identified by journal entries and would be addressed by the therapist who was responsible for overseeing the journaling component of the treatment model and individual treatment. The expectation was that each unit would have a therapist assigned to it who would interact fully with the youth in order to create a therapeutic environment. The Behavioral Health Unit at New Beginnings was instrumental in the development and implementation of the model, which initially was to be co-facilitated by the unit manager and the therapist on the unit. This designed changed between 2009 and 2010 when the system became totally unit-based and the unit manager became responsible for facilitating the groups. Currently the actual facilitation and monitoring of the substance abuse treatment within New Beginnings is under the supervision of the Deputy Superintendent of Treatment, and the facilitation of the groups fall under the direction of the Youth Development Representatives. There are several additional nuances of The Seven Challenges Model that have an impact on its effectiveness within New Beginnings. First, The Seven Challenges Model provides guidelines on group composition. These guidelines include not having more than ten youth to a group and having the Counselor be attuned to the need to segregate youth on key variables such as trauma, level and severity of drug and alcohol usage, etc. Within New Beginnings, youth are not separated by age nor are they separated by severity of offense. In addition, The Seven Challenges Model does not provide a structured evaluation of outcomes nor does it track outcomes of the model. Developing and implementing a structured evaluation is left up to the

14 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center 7 individual user. Technical assistance is provided on identifying appropriate outcome variables for residential settings which may include behaviors, drug use, increase or decrease in the use of restraints, grades, and scores from behavioral measures Discussion of Findings - The Seven Challenges program model is designed to be a holistic clinical program that is able to address every level of severity of drug and alcohol usage and/or addiction. During the training process and through the program guidelines, it is recommended that Counselors are mindful of the level of severity of drug and alcohol usage and/or addiction and group the participants based on these types of nuances. This approach is in conflict with the basis of the DC Model which operates on the foundation that, even though the youth on the unit are diverse in terms of age, offense, level of drug/alcohol use severity, etc. they all receive the same type of programming as a unit. This heterogeneity of the youth on the unit may impact the effectiveness of the group process. The model requires close oversight by the Behavioral Health Supervisor to monitor and direct the level of intensity based on the severity of the youth in treatment. This requires monitoring of journals and clinical meetings to gauge progress. The Behavioral Health Supervisor should structure the frequency and length of treatment based on the needs of the youth in treatment. As the Behavioral Health Supervisor has no authority over the YDRs who serve as Counselors, the process is not always adhered to in the manner in which the program is designed. For any treatment model used, the principles of the model should be infused across the entire programming in the facility. It is important to work with the staff to ensure that they don t see any substance abuse treatment program as strictly a drug and alcohol program but one whose foundation is integrated across all aspects of programming. This may require a mindset change of the leadership and key staff at the facility to understand that the principles espoused in the treatment process should be integrated and modeled across all aspects of operations and programming. This will require a coordinated approach to substance abuse treatment that includes training in the model foundation and implementation for non clinical staff and better communication across all units. This will facilitate the necessary buy-in and endorsement of the leadership which is critical for the effective implementation of any substance abuse treatment model at New Beginnings. The Seven Challenges is a not a highly manualized program and relies on the knowledge, training and skill set of the Counselor to be effective. It is recommended in the Seven Challenges guidelines and implementation materials that Counselors who run the treatment groups have some level of behavioral health experience and training so as to effectively address issues of substance abuse and mental health that may arise in the group process. In addition, the Seven Challenges sessions are not prescripted nor do they follow a curriculum-based structure but rather group content is guided by the youth and/or the Counselor, with the Counselor integrating a specific Challenge and making it a part of the group conversation. It is the position of this author that this reliance on the skill set of the Counselor does not support the use of staff who don t have Behavioral Health training and experience and are unfamiliar

15 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center 8 with Behavioral Health practice and principles. The structuring of the program relies heavily on the intuitiveness of the Counselor and the guidance of the Behavioral Health Supervisor (Clinical Director) to direct and guide the intensity of the treatment for the youth in the program. In the current setting, this may be a hindrance to the provision of treatment as opposed to an asset. In addition, the lack of evaluation of the program does not provide information or opportunities for documentation of process or outcomes, which would provide critical information on both the youth and the staff involved in the treatment process. Strengths The Behavioral Health Supervisor has done a good job in creating a therapeutic environment in treatment groups, i.e., ensuring that the appropriate components of the model (displaying posters, sign in process) are implemented. Group composition has changed to only include youth who are in need of substance abuse treatment as opposed to all youth. The fidelity of the model is being adhered to closer than in prior years. Weaknesses There is lack of: 1) consistency in how the counselors run the treatment groups specific to intensity and content; 2) evidence of support from all key stakeholders; 3) program measures; 4) monitoring and tracking of the Program Model outcomes; and 5) integration of all areas of New Beginnings in structuring a comprehensive approach based on The Seven Challenges model. Also, the broad age range of the youth within New Beginnings pose a challenge to implementing appropriate group treatment. The wide age range introduces developmental and experiential differences which may make it difficult for a counselor to reconcile in introducing program concepts and facilitating the input from the participants. The age difference may be challenging to manage for any program introduced. Finally, there is difficulty in adhering to the fidelity of the program model due to facility programming conflicts Recommendations and Action Steps The following recommendations and action steps are suggested in order to ensure that the treatment design that is implemented is adequate to meet the needs of the youth in the context of the current structure of correctional facility s overall model. Convene a workgroup consisting of DYRS Behavioral Health staff, New Beginnings leadership, and a subject matter expert to identify a substance abuse treatment model that is better adapted to the New Beginnings DC Model other than Seven Challenges. The workgroup should develop a workplan for implementation that includes identifying and hiring appropriate staff. A formal evaluation of any substance abuse treatment model implemented within New Beginnings should be designed and conducted to determine process and outcome effectiveness. Accurately assess the youth within New Beginnings so that they are appropriately triaged to homogenous groups based on level of severity and age.

16 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center 9 Structure treatment groups by level of severity. Implement an intervention for all youth in the system to provide prevention education intervention for who don t have substance abuse issues. Train all facility staff on the substance abuse model so that principles of the model are integrated in the daily functioning of the youth. Implement any substance abuse program in New Beginnings with fidelity.

17 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center Critical Area 2. Program Organizational Design Has the substance abuse and alcohol treatment program been implemented with fidelity at the facility as originally intended and designed? Have challenges been identified and resolved to ensure the successful implementation of the program? Observations The overall findings based upon key informant interviews, reviews of daily schedules, the YES data system, other relevant program documentation, and site visits observations conducted at New Beginnings suggest that while substance abuse treatment implementation is conceptualized as critical to programming, the day-to-day program practices have not been implemented with fidelity in terms of its adherence to the original program intent and design, quality of program delivery and exposure or treatment dosage delivered to youth. For example, according to data from YES, youth are currently receiving approximately 3.5 hours of substance treatment (specifically Seven Challenges) per month which does not meet the program model s minimum requirement of 6 hours per month. Also, although substance abuse treatment is incorporated into the programming of each model unit, there is no standardization of implementation across units and no clear identification of staff responsible for the systematic assessment, implementation, monitoring and quality control, continuous improvement and outcomes of substance abuse treatment within New Beginnings Discussion of the Findings There were several factors identified that impacted the implementation fidelity of the substance abuse treatment program within New Beginnings and, consequently, the effectiveness of the program. These factors include having effective organization and strong administrative support, qualified staff and delivering the appropriate exposure or treatment dosage to effectively meet the youths substance abuse needs. Administrative organization and support are critical factors related to successful program implementation because while decisions regarding the selection of a particular program model typically transpire at the administrative level, decisions concerning the implementation of a program are generally made at lower organizational levels (i.e., by unit managers, juvenile justice institutional counselors and Youth Development Representatives). Also, administrators have the authority to allocate resources and make organizational changes that can facilitate and more clearly demonstrate commitment to a program. Many of the stakeholders interviewed expressed an overwhelming concern about New Beginnings capacity to effectively implement a substance abuse treatment program within the current organizational structure. The Behavioral Health Supervisor at New Beginnings is responsible for managing the Behavioral Health Services at New Beginnings, including substance abuse treatment. However, within the current organizational structure of New Beginnings, the Behavioral Health Supervisor does not provide oversight or supervision of the actual implementation of the substance abuse treatment or the Youth Development Representatives (YDRs) who are responsible for delivering the treatment services to youth. Currently, the Deputy Superintendent of Treatment is responsible for implementing and overseeing the treatment services for committed youth at New Beginnings and supervising a staff of unit managers, juvenile justice institutional counselors, recreation specialists and YDRs. Both the New Beginnings and Health Services staff,

18 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center 11 as well as a representative from the substance abuse treatment model being implemented at New Beginnings expressed that having supervision and oversight of SA treatment with the Behavioral Health Supervisor would contribute to the treatment fidelity. The staff within the Behavioral Health Unit is more qualified to monitor the implementation and structure the appropriate treatment process for the youth. The Superintendent and leadership of New Beginnings work very closely with the DYRS Health Services Administration (HSA) which is responsible for the design, development, coordination, delivery and evaluation of a 24-hour comprehensive continuum of quality adolescent medical and behavioral health care services and supports at New Beginnings. The Behavioral Health Supervisor at New Beginnings, who reports to the Chief of Health Services/Medical Director, is responsible for managing the Behavioral Health Services at New Beginnings, including substance abuse treatment. As stated earlier, however, under the current organizational structure of New Beginnings, although substance abuse treatment falls under the umbrella of Behavioral Health, the Behavioral Health Supervisor does not have supervisory authority over the staff who deliver the substance abuse treatment services, and as such, does not have authority to mandate critical components of substance abuse treatment implementation within the facility. Currently, this authority is granted to the Deputy Superintendent of Treatment. For example, substance abuse treatment groups are scheduled once a week and conducted by the YDRs, the leaders of the model unit, as opposed to more qualified behavioral health counselors. During the time of this assessment, several units had suspended group treatment activities for a number of reasons, including strife within the unit amongst the youth. It was also conveyed that the treatment groups did not routinely meet as scheduled if the YDRs determined there were other priorities that needed to be addressed at a given time. As stated earlier, per data generated by YES, youth are receiving an average of 3.5 hours of substance abuse treatment per month, which is not close to the minimum number of hours recommended by the treatment model that is being implemented at New Beginnings. This minimum is one 90 minute session per week which averages to a minimum of 6 hours of substance abuse treatment per week. Depending upon the youth s level of severity, six hours may not be enough in order for the substance abuse treatment process to be effective. Initially, the program was to have included at least two weekly treatment groups, which changed as programming at the facility changed. It was expressed by staff that the one treatment group per week was not the appropriate dosage for youth on the units. Behavioral Health staff felt that they did not have the authority to increase the number of groups or restructure the manner in which the program was being implemented across the units. It is evident, however, that progress has been made toward ensuring that substance abuse treatment is being provided to those youth in need of treatment. Initially, based on the foundation and tenets of the DC Model, upon which New Beginnings programming is structured, all youth were required to engage in substance abuse treatment groups regardless of whether the youth were given a substance abuse diagnosis which recommended treatment and were required to participate in the same activities. Recently, the New Beginnings

19 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center 12 Superintendent amended their practices to provide substance abuse treatment only to those youth evidencing a need for treatment. This corrective action suggests there is interest and an attempt from the leadership of New Beginnings to improve the delivery of substance abuse treatment to better serve the needs of the youths, and to begin to implement the program with better fidelity. It was also conveyed that there is support from New Beginnings leadership and Health Services leadership to have substance abuse treatment fully implemented by the Behavioral Health Unit, which would facilitate communication and coordination of services from those expert in the area. Moving the implementation of substance abuse treatment under the Behavioral Health unit will be critical in ensuring the fidelity of any model implemented at New Beginnings. Strengths The New Beginnings Superintendent recognized the need to amend the traditional substance abuse treatment design providing treatment to all youth regardless of need to a more effective, efficient tailored design ensuring that substance abuse treatment is provided only to those youth in need of treatment in the intensity needed. Weaknesses There is no standardized approach to the assessment and implementation of substance abuse treatment within New Beginnings that is tailored to the specific needs of each youth. While substance abuse treatment falls under the jurisdiction of Health Services/Behavioral Health, the Behavioral Health Supervisor has no authority over the implementation of the substance abuse treatment process. Youth are not receiving the appropriate dosage of substance abuse treatment based on guidelines and due to the lack of a standardized approach and appropriate oversight by qualified staff. Substance abuse treatment groups are scheduled and conducted by YDRs as opposed to more qualified behavioral health counselors Recommendations and Action Steps The following recommendations and action steps are suggested for New Beginnings leadership and key staff to better prioritize and facilitate substance abuse treatment implementation at the facility: Leadership of New Beginnings must demonstrate that substance abuse treatment is a priority within the facility by standardizing practices to ensure appropriate enforcement of the treatment protocol. Identify and engage qualified counselors under the DYRS/New Beginnings Behavioral Health Unit to facilitate the group treatment sessions and engage YDRs as part of the process in translating the principles and foundations of substance abuse treatment model into practice outside of the treatment groups. Develop a New Beginnings substance abuse treatment business process that clearly identifies roles and responsibilities of staff involved in the substance abuse treatment process.

20 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center 13 Ensure that substance abuse groups are conducted routinely with minimal changes and in accordance with the appropriate treatment dosage prescribed for the youth.

21 An Assessment of the Substance Abuse Services at the New Beginnings Youth Development Center Critical Area 3. Youth Assessment Are the youth adequately assessed to determine their substance abuse needs, and as such, how is this information used to inform, structure and implement a treatment plan and subsequently, treatment? Observations Based on guidelines for behavioral health assessments as delineated in Goals Five and Eight of the Jerry M workplan, youth who enter New Beginnings are to receive an initial behavioral health screening and assessment within 24 hours of their arrival at the facility. Per the guidelines (Goal V.A.1.a.), this screening is designated as the MAYSI-2 or an equivalent empirically supported initial behavioral screening and assessment measure, and is to be performed by appropriately trained staff. Also, per the workplan (Goal V.A.5.d.), the GAIN-Q or an equivalent assessment is to be administered within five working days of commitment if the youth scores about the Caution or Warning cut-off on the substance abuse scale of the MAYSI-2 or its equivalent. A review of the Behavioral Health Unit Workplan Scorecard for New Beginnings indicated a compliance rate between 81%-91% from January July 2011 for all indicators which includes the conduct of the initial MAYSI-2. These indicators are based on the requirements in the Jerry M workplan and include the initial behavioral health screening. It is important to note that Scorecard flagged the process of conducting the subsequent assessment to identify substance abuse severity as to be in need of correction in material deficiencies in intake process. This finding indicated that, at the time of this report, this critical assessment was not being conducted consistently and/or within a timely manner after the initial assessment. This finding is no longer the case and the Behavioral Health Unit at New Beginnings was in 100% compliance based on the Jerry M requirement. Review of current data indicated that all youth entering New Beginnings receive the MAYSI-2 within the requisite 24 hour timeframe. In addition, review of the current follow-up data indicated that while if those youth flagged on the MAYSI-2 did not receive a GAIN-Q or an equivalent assessment, it was due to the fact that they had a prior assessment on file. One youth did in fact receive a follow-up SASSI while at New Beginnings. The SASSI is categorized as an equivalent assessment. It is important to note that, while the Unit was in compliance, observational and interview findings suggest there is no standardized process for youth assessment and the youth are not consistently assessed for substance abuse needs upon entering New Beginnings as a practice standard. Currently, youth who have documented records of substance use and abuse are triaged into the substance abuse treatment program implemented at New Beginnings. While some youth enter the facility with a valid substance abuse assessment on file, according to Behavioral Health staff, many do not. It was indicated that the Global Appraisal of Individual Needs Quick (GAIN-Q) was completed for youth at New Beginnings by District of Columbia Court Social Services (CSS) at one point in time, however, this practice was discontinued. Until recently, no assessment and screening is being performed by DYRS staff to assess youth upon entry into New Beginnings. This finding has changed with the training of four key staff to conduct the