8/29/2011. Welcome. How Do I Ask Questions? Thank you for joining us today. The webinar will begin in a few moments.

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1 Welcome How Do I Ask Questions? Thank you for joining us today. The webinar will begin in a few moments. If you are experiencing technical problems with the GoToWebinar program, contact the GoToWebinar help desk: 1 (800) Webinar ID: Type and send your questions through the Question and Answer log located on the bottom half on your panel/dashboard. TEXT PAGE TEXT PAGE A Program of the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment & the Administration on Children, Youth and Families Children s Bureau Office on Child Abuse and Neglect NCSACW Mission: To develop knowledge and provide technical assistance to Federal, State, local agencies and Tribes to improve outcomes for families with substance use disorders in the child welfare and family court systems The Role of Recovery Specialists in Substance Abuse Treatment, Child Welfare and Dependency Courts August, 2011 Sandy Robinson Consultant Children and Family Futures 4940 Irvine Blvd, Suite 202, Irvine, CA ncsacw@cffutures.org 1

2 Agenda Sometimes Child Welfare and Substance Abuse Treatment are Worlds Apart Purpose of using a substance abuse specialist model Roles and responsibilities Training and supervision Location and settings Understanding values and agreements Funding Function in the system Questions Child Wlf Welfare Substance Abuse Treatment 6 Summary Substance use disorders are NOT just one more thing They are central, critical, and urgent A thorough response requires strategic thinking It requires a strategic multi-year plan It requires work at all ten bridges of linking across systems The best prevention for children remains treatment for their parents Purpose Of Utilizing Substance Abuse Recovery Specialists Reduce costs of out of home placements and/or reduce time of children in foster care Remove barriers and improve linkages between CWS and treatment to better serve clients Improve the capacity of CWS to serve parents with substance use disorders Increase collaboration between agencies Ensure reasonable efforts TEXT PAGE 8 2

3 Purpose Of Utilizing Substance Abuse Recovery Specialists Roles and Responsibilities Decrease time to assess and enter treatment Increase compliance with treatment Case management Screening, assessment, referral, and engagement into Treatment Support to parents while in treatment Increase 12 month permanent placements Conduct home visits it (CT, DE, IL, Sacramento) Urine testing (CT, DE, IL, Sacramento, San Diego) Increase family reunification rates Consultation and Information sharing with CW and/or courts Training to CW and potentially the court Decrease time in foster care TEXT PAGE 9 Develop and implement substance abuse capacity building plans for CW (MA) TEXT PAGE 10 Training and Supervision Location and Settings Licensed/certified addiction counselor Licensed clinical SW with addiction certification (CT) Supervised by child welfare (CT, NH, WA) Supervised by contracted service provider (IL, Sacramento, San Diego) Dual supervision (DE, MA) Regular meetings to maintain program purpose and/or foster collaborative relationships Receives CW New Worker Training (DE, MA, NH) Employed by state, county CW agency, community-based AOD treatment agency, contracted service provider or Self-employed and contracted by CW Area/regional/county/district CW offices (CT, DE, MA, NH, WA) Contracted service provider s office, near to juvenile court (IL, Sacramento, San Diego) Participates in cross training

4 Underlying Values and Agreements Funding MOU or other agreement formally outlines joint values and principles for the program (Sacramento, WA) MOU or other agreement outlining joint values influences the implementation of program, but was not developed for the program, specifically (Sacramento, MA) MOU or other agreement outlines systems and or other programs roles in program implementation (CT, DE, IL, San Diego) State funds CT, DE, MA Federal funds (i.e., Title IV-E, IV-B) IL and NH Multiple l sources (i.e., partial state t funding, tobacco settlement, agency budget reallocation) Sacramento, San Diego and Washington Substance Abuse Specialists Substance Abuse Specialists TEXT PAGE TEXT PAGE 4

5 Substance Abuse Specialists Program Context Sacramento County population: 1.5 million Between Oct 2006 and Sept 2007, there were 1862 child abuse/neglect referrals accepted for investigation An estimated 70 to 80% of child welfare cases involve families affected by substance use TEXT PAGE Sacramento County Prior to STARS and Dependency Drug Court Reunification rate about 20-25% Parents unable to access substance abuse treatment Social workers, attorneys, courts often uninformed on parent progress Drug testing not uniform and results often delayed Sacramento County after STARS and Dependency Drug Court Reunification rates at 40 45% With Recovery Specialist & Drug Court Graduation, Reunification rates at 75% Reunification is occurring faster Reunification is occurring faster Parents truly have treatment on demand All parties involved in the case are informed at every stage of treatment All parents receive random observed instant drug testing 5

6 Primary Substance Abuse Specialist Function Engaging Parents into entering treatment and supporting them through treatment completion WHY? Without treatment most parents with genuine substance abuse issues will most likely fail leading to increased time away from home, foster care etc. 21 Regardless of Model - Engagement Strategies are Universal Goals For Parents: Attend all required group and individual alcohol and drug treatment sessions Attend all scheduled Recovery Specialist (mentor etc.) meetings Attend specific number of AOD support / 12-step meetings weekly Attend all required AOD activities Complete all AOD requirements of the court Drug Test Randomly Produce negative drug tests 22 Three Standard Court Orders Treatment Substance Abuse Specialist Roles Treatment Drug and Alcohol Testing Specialists Contacts Recovery Support Groups 23 Primary purpose is to facilitate entry into treatment If known, provide parent with treatment days and times written (pocket calendar is best) Upon assessment help parent make phone call to treatment for initial appt If needed provide number, documentation etc. of public transportation Provide treatment documents such as brochure or program rules Supply a map to treatment facility (best practice take them to facility the first time) 24 6

7 Drug and Alcohol Testing Substance Abuse Specialist Roles Substance Abuse Specialist Contacts Substance Abuse Specialist Roles From the start, set parent mindset regarding testing. Tests are used to provide proof of compliance. System already knows about substance abuse problem Remember Always allow for honesty first! Demonstrate how honesty about use helps case. Social Worker and Court perception Thoroughly explain consequences of deception worse than positive test Explain in detail the method of testing used. Help the parent understand what exactly they are bi being subjected to. These serve as the foundation for the relationship between parent and specialist Should begin with intensity and frequency and taper down as case progresses (When possible, meetings should cater to parent needs treatment, home, work etc.) Utilize these contacts to collect paperwork and needed info reduce impact Unlike other requirements, allow for some deviation (only if testing would not have occurred) Attendance of Support Groups Substance Abuse Specialist Roles How Can You Make All Of This Work? Cross training and training on how to use the specialist Overcome resistance to attendance by fully explaining nature of meetings attending Using meeting schedule, highlight g meetings close to home work etc. Highlight meetings with childcare or any other special need Utilize buddy system other parents or alumni can attend meetings with parent Steer parents to beginner meetings and sober functions Specialists background and expertise Location of specialist Specialist works with client throughout h t length of case Collaborative relationship and constant communication Buy in from different systems Explain to parent the need to attend these meetings treatment is finite but meetings offer lifelong support 27 Integrative practice Sustainable funding 28 7

8 How Can You Make All Of This Work? Specialists background and expertise Location of specialist Sacramento County Recovery Specialists/Dependency Drug Court Evaluation Data Collaborative relationship and constant communication Buy in from different systems Sustainable funding 29 Treatment Outcomes: Admission Rates*** (Ever been in AOD treatment) Treatment Outcomes: Discharge Status Perce ent Comparison With RS ***p<.001 Comp n=111; DDC n=2138 Source: CalOMS rcent Per No significant difference Satisfactory Unsatisfactory Comparison Court Ordered RS Comp n=111; DDC n=2138 Source: CalOMS 8

9 Treatment Discharge Status by Primary Drug Problem Child Placement Outcomes at 36-months nt Percen Reunification*** Adoption*** Guardianship*** FR Services*** Long Term Other Placement*** Comparison Court Ordered ***p<.001 Comp n=111; DDC n=2138 Source: CalOMS **p<.01; ***p<.001 Comp n=173; DDC n=1343 Source: CWS/CMS Child Reunification Rates Over Time Child Adoption Rates Over Time Comp n=173; DDC 12 mos=2818; 24 mos= 2087; 36 mos=1343 Source: CWS/CMS Comp n=173; DDC 12 mos=2818; 24 mos= 2087; 36 mos=1343 Source: CWS/CMS 9

10 Long Term Child Placement Rates Over Time Child Reunification Rates by DDC Graduation Status Over Time Comp n=173; DDC 12 mos=2818; 24 mos= 2087; 36 mos=1343 Source: CWS/CMS Comp n=173; DDC n=2138 Source: STARS; CWS/CMS Acknowledgements Adaptive Continuing Care Mark D. Godley Chestnut Health Systems This work was supported by: Westat Subcontract No. s8440, SAMHSA Contract No. HHSS I NIDA Grant No: 5-R37-DA11323 The content of this presentation does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. 10

11 Presentation Aims What is adaptive continuing care Key elements of adaptive continuing care Describe two approaches to adaptive continuing care Results Adaptive Continuing Care Adaptive continuing care is treatment that is tailored and or modified based on a client s symptoms, status, and level of functioning. Adaptive Continuing Care: Key Elements Telephone-based Adaptive Continuing Care for Adolescents Monitor clients discharged from treatment for substance use disorders at planned intervals Use standardized instrument and approach to client monitoring Decrease or increase contact frequency depending on client functioning Provide support or stepped up care depending on client functioning Seattle, WA Tucson, AZ Bloomington, IL Fitchburg, MA 11

12 Adaptive Call Structure Weekly calls during the first 90 days after discharge from treatment, then monthly Call frequency increases or decreases depending on how adolescent is doing Texting sessions are an option If adolescent cannot be contacted after 90 days of attempts, the case is closed Telephone Protocol Greeting and general conversation Ask about whether they experienced any triggers to use since last call If no use but triggers discuss how they overcame, praise, and ask them how they can generalize Discuss and agree to recovery goals for the next period between calls If use, ask if they are still using and make referral back to a counselor Provide assistance with referral (call, arrange transportation, etc) Average Length of call by Week in Minutes: Seconds Percent of Adolescents Completing Planned Telephone Support Sessions 19: : :24 12:00 9:36 7:12 4: % 67% 65% 57% Attempted Completed 2: :00 4/17/2010 5/1/2010 5/15/2010 5/29/2010 6/12/2010 6/26/2010 7/10/2010 7/24/2010 8/7/2010 8/21/2010 9/4/2010 9/18/ /2/ /16/ Bloomington Fitchburg Seattle Tucson 12

13 Telephone Support Session Data (n=81) Outcome Measures Pre-post change scores in the following areas collected with the Global Appraisal of Individual Needs (GAIN): Feb-April 2010 May-July 2010 Prosocial Activities (including 12 step attendance) Days of substance use in the community Substance Problem Scale 10 0 % of Sessions ending with goals % of Sessions with goals completed Self-Help Activity Scale Outcomes of Adaptive Telephone Continuing Care % Pro-Recovery Activities % Participation i in -.11 Substance Use +.56 Telephone Frequency Continuing Care 37% Substance- Related Problems Intake 3 Months Adaptive Telephone Continuing care was compared to a matched control group receiving standard referrals for continuing care only. All coefficients >.10 are statistically significant 13

14 Satisfaction with Telephone Support (n=25) Early Re-Intervention (ERI) Experiment and Hypotheses 100% 90% 80% Monitoring and Early Re- Intervention Reduce Time to Readmission Less Successive Quarters Using Less Risk Behaviors, MH and Crime 70% 60% 50% 40% 30% 20% 10% 0% sometimes-almost always/almost never/almost never thought calls were thought telephone would recommend always liked always thought thought telephone the right amount of calls were the right calls longer than the receiving calls telephone support support worker was frequency length of time first 3 months postdischarge worker was kind too demanding and encouraging Relative to Control, RMC will reduce the time from relapse to readmission The quicker the return to treatment, the less successive quarters using in the community The less quarters using in the community, the less HIV Risk Behaviors, Mental Health and Crime Problems Source: Dennis et al 2003, 2007; Scott et al 2005, in press Recovery Management Checkups (RMC) Quarterly monitoring after treatment Linkage meeting/motivational interviewing to: provide personalized feedback to participants about their substance use and related problems, help the participant recognize the problem and consider returning rning to treatment, address existing barriers to treatment, and schedule an assessment. Linkage assistance reminder calls and rescheduling Transportation and being escorted as needed Treatment Engagement Specialist ERI-2 Time to Treatment Re-Entry at Year 4 Percent Readm mitted 1+ Times 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Time from relapse to readmission reduce by 78% (45-13 = -32 months; d=-.41) The size of the effect grew every quarter Months from 1st Follow-up In Need for Treatment, Source: Scott & Dennis (2009); Dennis & Scott (in press) RMC increases the odds of re-entering treatment over 4 years by % ERI-2 RMC* (n=198) 48% ERI-2 OM (n=195) Wilcoxon-Gehen statistic (df=1) = 28.60, p<.001 OR=3.1, p<.05 14

15 Positive Consequences of Early Readmission Checkups and Early Readmission to Treatment were associated with: Less substance use and problems Longer periods of abstinence More attendance and engagement in self help activities Above were associated with: Fewer HIV risk behaviours Less illegal activity, arrests, and time incarcerated Fewer mental health problems Less utilization and costs to society Practice Implications Adaptive Continuing Care is state-of-the-art and improves outcomes but must consider: What will the frequency of client contact be? How will regular client contact be maintained? Need to have client information system to track and manage contacts with clients The longer you plan to retain clients in continuing care the greater the cost Costs can be decreased by using trained, wellsupervised volunteers Source: Scott & Dennis (2009); Dennis & Scott (in press) Register Now Questions and Discussion Gaylord National Resort and Convention Center on the Potomac National Harbor, MD 15

16 Contact Information Sandy Robinson Children and Family Futures 4940 Irvine Blvd, Suite 202 Irvine, CA Mark D. Godley, Ph.D. Chestnut Health Systems 448 Wylie Dr. Normal, IL