Connie Neal, MSW & Lisa Shannon, PhD, MSW. NADCP Annual Meeting, July 2015

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1 Enhancing the Continuum of Care and Expanding the Service Population via Assertive Community Treatment in Rural Drug Courts: Application, Implementation, Sustainability, and Outcomes Connie Neal, MSW & Lisa Shannon, PhD, MSW NADCP Annual Meeting, July

2 Presentation Goals Individuals will understand the fundamentals of Assertive Community Treatment (ACT) as well as necessary modifications for implementing with a rural substance abusing population. Individuals will understand the key roles/responsibilities of the ACT and drug court team members. Individuals will understand quantitative and qualitative outcomes associated with the implementation of the ACT model in adult drug court sites. 2

3 BACKGROUND 3

4 Substance Use and Rural Areas Kentucky is predominantly a rural state. Historically there are differing substance use trends rates of prescription opiate and benzodiazepine use higher than urban areas There is some evidence to suggest injection drug use rates are also higher in rural areas (Shannon et al., 2009; Shannon et al., 2010) Heroin use is also increasing; however, this trend appears to be statewide. 4

5 Rural Appalachia, Disparities Counties are classified as economically distressed based on the three year unemployment rate, per capita market income, and the poverty rate (ARC, 2012). 5

6 Any Illicit Drug Use Other than Marijuana in the Past Month among Persons aged 12 or Older: Percentages, Annual Averages Based on 2002, 2003, and 2004 NSDUHs (SAMHSA, 2006) 6

7 APPLICATION 7

8 Assertive Community Treatment in Kentucky Drug Courts Assertive Community Treatment (ACT) is an evidenced-based practice designed to provide effective treatment and support services to the chronically mentally ill by extending services to those most difficult to serve. The Kentucky Administrative Office of the Courts (AOC) has adapted the model to address the needs of an addicted population and implemented in nine drug court sites over the past eight years. 8

9 ACT Implementation Integrates an existing evidence-based practice into drug court community-based programs targeting individuals with primarily substance abuse problems. Perry & Floyd sites were funded in October, 2008 (projects ended 2012) Knox/Laurel and Hardin sites were funded in October, 2009 (projects ended 2013) Daviess site funded in October, 2010 (project ended 2014) Knott/Magoffin site funded in October, 2011 (project ending 2015) McCracken and Warren sites funded in October 2012 Clark/Madison site funded in August

10 Implementation Sites 10

11 Kentucky Drug Court Model Unified Statewide Drug Court System Overseen by the Kentucky AOC, Statewide Services Department, Division of Drug Courts Executive Officer and Manager Programs are either single or multi-county jurisdictions, mainly rural, and are operated locally by Drug Court Staff 11

12 Kentucky Drug Court Model Program Supervisor: Responsible for administration of the program and supervision of drug court case specialists. Case Specialists: Responsible for all supervision, monitoring and case management of drug court participants. (Cases are transferred from the Department of Probation and Parole to the drug court via court order there is no probation & parole involvement). Assistance with curfew checks and home visits provided by local law enforcement agencies via either Memorandums of Understanding or verbal agreements. 12

13 Kentucky Drug Court Model Treatment services are provided by the local Community Mental Health Centers via Memorandum of Agreements with the AOC. Ancillary services are provided by local community service agencies. 13

14 ACT in Kentucky Drug Courts In order to begin implementing ACT in Kentucky Drug Courts, AOC partnered with a local university to write grant proposals to the Substance Abuse and Mental Health Services Administration. Along with the traditional drug court approach to supervision and case management, participants in grant-funded services receive intensive support and assertive outreach in their own living and working environments via ACT. ACT has an anticipatory approach and provides for intensive, ongoing assessment of immediate and long term recovery related needs. Ideally, the implementation of ACT in drug court settings will increase access to needed services and decrease the likelihood of relapse and related criminal activity. 14

15 Fundamentals of ACT 15

16 ACT Goals (Stein & Santos, 1998) Maintaining a substance-free lifestyle Lessening symptoms of co-occurring disorders Maintaining decent and affordable housing Minimizing involvement with law enforcement and the criminal justice system Acquiring and keeping a job Maintaining a good general health status Helping the individual meet other goals 16

17 ACT Key Principles (Burns & Santos, 1995) Services are provided in the clients home as much as possible Team members practice assertive outreach to clients Highest possible intensity of services Caseloads are small Team members available 24/7 17

18 ACT Key Principles (cont) Relationship with team, not individual Team works with community to provide supportive relationships Team provides continuity of staffing 18

19 ACT Evidence Base A review of the extant research suggests strong support for the ACT approach. Specifically, ACT is associated with: 1) reduced symptom severity; 2) enhanced residential stability; 3) enhanced role functioning, including employment status; and 4) improved quality of life (Stein & Santos, 1998). Developed and tested for persons with severe mental illness, however the outcomes associated with ACT directly overlap with goals of the drug court program. 19

20 IMPLEMENTATION 20

21 ACT Approach ACT uses a trans-disciplinary approach Team members conduct comprehensive assessments and intense ongoing evaluations The entire team is jointly responsible for implementing and monitoring the plan Weekly (minimum) team meetings with ongoing transfer of information, knowledge, and skills shared among team members (cross-training) Participant has an active voice in plan development and method of implementation 21

22 ACT Activities Provides intensive and ongoing assistance with: Activities of daily living Housing Family life/social relationships Employment/education Managing finances Health care/medications Counseling/co-occurring disorders/higher levels of care 22

23 ACT Aspects Rather than referring participants to multiple service agencies, the ACT team provides direct services as much as possible. Rather than working with participants solely in the office environment, ACT team members work with participants in the environments where problems and stresses arise where they need support and skills (i.e., home, work, neighborhood). 23

24 ACT Aspects No limit on length of services, may have decreased contact with participants over time, but remain available if/when needed Actively solicits input to clearly identify barriers to recovery and input on goals and methods to remove barriers Participants who are seen as non-compliant are given more intensive services rather than terminated 24

25 Grant-Specific Modifications 25

26 Focus on Substance Use While ACT was primarily developed for persons with severe mental illness, these projects utilize ACT for those with dual diagnoses as well as those with only substance use disorders. Thus, at times, these projects modify ACT by substituting substance use for mental health. This modification is minor and has been considered valid (Stein & Santos, 1998). Being free of substance use has always been a goal of ACT, but not the principle focus as it is in these projects. 26

27 Less Medically Oriented While the traditional model involves a medically-oriented team, this ACT team is comprised of the counselor, case manager, peer recovery specialist, the ACT Clinical Supervisor and the Drug Court Program Supervisor/Case Specialist. 27

28 Addressing Gender/Culture In order to address gender issues, if possible two peer recovery specialists are hired, a male and a female. The use of home visitation and assertive outreach to clients has been modified for cultural issues related to fear and suspicion about governmental services. 28

29 Key Roles & Responsibilities 29

30 Key Personnel In addition to the drug court team in this adapted model integral ACT team members are the: counselor, case manager, and peer recovery specialists. This model adds an additional counselor and case manager to enhance and target services to individuals with the most significant needs. 30

31 Drug Court Staff Liaison with ACT team and traditional drug court team Community Supervision Assist participant with identifying barriers to recovery and plans to remove them Overall support 31

32 Counselor Individual/group/family counseling Addresses mental health/co-occurring disorders Assist with medication needs and monitoring compliance Evaluate for higher levels of care Assist participant with identifying barriers to recovery and plans to remove them Overall support 32

33 Case Manager Conduct initial and ongoing needs assessments Assist participant in identifying barriers to recovery and plans to remove them If team cannot provide services, refers to appropriate service agency and follows up to ensure service is received Services are located/developed to fit participants stated goals/needs Visits to home and place of employment Assist with most basic recovery needs (i.e., transportation, food, shelter) Overall support 33

34 Peer Recovery Specialist Assist participants with identifying barriers to recovery and plans to remove them Assist participants with identifying stresses and plans to deal with them Visits to home and place of employment Assist with most basic recovery needs (i.e., transportation, food, shelter) Relapse identification and prevention Overall support 34

35 SUSTAINABILITY 35

36 Sustainability Kentucky has been fortunate to receive multiple grants from the Substance Abuse and Mental Health Services Administration (SAMHSA) to implement this service enhancement. However, multiple sites have sustained the model post-grant via: Partnerships with community agencies Leveraging resources 36

37 Discussion How did the services provided by the grant influence or compliment the system of care? What components were critical to post-grant sustainability? 37

38 OUTCOMES 38

39 Process Evaluation Process evaluation data help monitor the implementation from provider perspectives. Provides descriptive information about program services, program changes following implementation, perspectives on program successes, and proposed program recommendations. 39

40 Administrator/Staff Interviews Face-to-face interviews were conducted with administrators and staff directly involved in the project implementation/services from the grant sites. Interviews were scheduled at the convenience of the participants and lasted approximately fifteen minutes. 40

41 Major Accomplishments Improvements to participants quality of life (i.e., education, financial assistance, transportation, wraparound services) Reduced substance use Reduced barriers (i.e., new teeth/dentures, identification) Ability to serve more participants Peer support services allows for relationships to be built with community agencies 41

42 Barriers Communication/collaboration at start-up Referral process to the ACT team Staff turnover Availability/amount of wraparound funds Getting individuals into treatment/services more quickly 42

43 Accomplishment of goals Criteria for Judging Success Elimination/reduction of barriers Improved quality of life Sobriety Employment Program compliance (i.e., phasing up, continued service utilization) 43

44 Outcome Evaluation The outcome evaluation assesses the effects of the grant-funded program on participants receiving enhanced services at baseline and six months post-baseline. This component of the evaluation examines baseline characteristics of clients entering the program and changes in key domains. 44

45 Participants Participants were 384 individuals who completed a baseline and followup interview as part of an outcome evaluation project. The outcome evaluation project focused on the Kentucky Drug Court sites with active ACT funded projects in: Clark/Madison, Knott/Magoffin, McCracken and Warren counties. These sites were included because all had received grant funding from the Department for Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) to enhance existing services. 45

46 Measures Government Performance and Results Act (GPRA) - derived from the ASI, the GPRA items provide useful measures of current substance use and related behaviors. In addition to GPRA: Addiction Severity Index-5 th Edition: The ASI is used to measure life problem areas including psychological/mental health status, physical health status, housing, employment, drug and alcohol use, legal, and family-social functioning (McLellan et al, 1985; McLellan et al., 1992). 46

47 Procedures Outcome evaluation data are collected at: 1) baseline, 2) 6 months post-baseline, and 3) discharge. Baseline and follow-up data were collected by a Research Assistant (RA) who interviewed program participants for the CSAT evaluation. Once the program coordinator identified a potential participant, the RA met with the participant, provided information about the evaluation, discussed components of informed consent, and if the participant agreed, administered the evaluation interview through a face-to-face interview. Evaluation data were collected via a laptop computer with the CSAT Evaluation Data Entry System (CEDES). 47

48 Baseline Characteristics (N = 384) 48

49 Participant Demographics 48% female 52% male 94% White 31.2 Average Age 38.8% Employed full-time 49

50 Participant Demographics 48.4% Never married 20.1% Divorced 14.8% Married 44.5% High school diploma/ged 30.0% Some college or more 25.5% Less than high school diploma 50

51 Substance Use, Ever (Baseline) Alcohol Marijuana 96.6% 96.4% Opiates Benzodiazepines Cocaine 74.0% 85.4% 80.7% Methamphetamine 58.6% Hallucinogens Crack Cocaine 46.9% 45.1% 51

52 Mental Health, Past 6 Months (Baseline) Anxiety 53.9% Depression 45.1% Understanding 39.6% Prescribed Mediciation 20.1% Violent Behavior 14.3% 52

53 OUTCOMES DATA 53

54 Follow-up Rates Excellent follow-up rates! The overall follow-up rate for the period of data collection (02/ /03/2015) was 94.2%. Individual sites ranged from a high of 98.1% follow-up rate to a low of 89.4%. 54

55 Changes in Employment Status 18.0% 16.3% 38.8% 45.8% 46.1% 38.6% 15.1% 15.6% Full-time* Part-time Unemployed* Baseline Follow-up * p<.05 55

56 Changes in Past 6 Month Abstinence Rates Alcohol Abstinence*** 55.2% at intake 57.1% 86.7% at follow-up Drug Abstinence*** 28.9% at intake 167.5% 77.3% at follow-up *** p<

57 Changes in Past 6 Month Mental Health Baseline Follow-up 20.4% 21.7% 37.6% 45.1% 35.9% 53.9% 42.2% 39.6% 51.0% 24.7% 14.3% 7.0% Depression* Anxiety** Understanding*** Violent Behavior** *p<.05, **p<.01, **p<.01 57

58 Changes in Social Connectedness Baseline Follow-up 132.3% 84.1% 22.3% 77.9% 95.3% 36.2% 114.6% 9.6% 20.6% 32.1% 29.2% 22.1% Non-religious self-help groups*** Religious self-help groups*** Other recovery groups* Interaction with family and friends*** *p<.05, ***p<

59 Changes in Criminal Justice Involvement Arrests Past 30 Days*** 29.7% at intake 62.3% 11.2% at follow-up *** p<

60 Evaluation Considerations No comparison group can not definitely determine the cause of the change, the service enhancement or drug court services, in general. 60

61 Acknowledgements Chief Justice Minton, Laurie Dudgeon, Connie Payne, Connie Neal The Administrative Office of the Courts including: Judges Drug court teams Community Mental Health Centers Other community partners - treatment providers, doctors, other service providers Evaluation team members 61

62 References Appalachian Regional Commission. (2012). County Economic Status and Number of Distressed Areas in Appalachian Kentucky, Fiscal Year Retrieved from the World Wide Web on March 18, 2015 from: FY2012Kentucky.pdf. Burns, B. & Santos, A. (1995). Assertive community treatment: An update of randomized trials. Psychiatric Services, 46, McLellan, A., Kushner, H., Metzger, D., & et al. (1992). The fifth edition of the addiction severity index. Journal of Substance Abuse Treatment, 9, McLellan, A., Luborsky, L., Cacciola, J., & Griffith, J. (1985). New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of Nervous and Menta Disease, 173, 423. Shannon, L., Havens, J.R., & Hays, L. (2010). Examining differences in substance use among rural and urban pregnant women. The American Journal on Addictions. Shannon, L.M., Havens, J.R., Mateyoke-Scrivner, A., & Walker, R. (2009). Contextual differences in substance use for rural Appalachian treatment-seeking women. The American Journal of Drug and Alcohol Abuse, 35(2), Stein, L. & Santos, A. (1998). Assertive Community Treatment of Persons with Severe Mental Illness. New York: Norton Books. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2006). Results from the 2005 national survey on drug use and health. Rockville, MD: Office of Applied Studies. 62

DESCRIPTION OF FOLLOW-UP SAMPLE AT INTAKE SECTION TWO

SECTION TWO DESCRIPTION OF FOLLOW-UP SAMPLE AT INTAKE 7 2.1 DEMOGRAPHIC CHARACTERISTICS Table 2.1 presents demographic descriptive data at intake for those who were included in the follow-up study. Data