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 changeAchieving key SA and Child Welfare outcomes Lessons learned . 3. The Need for Empowerment Methods.
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1. 2010 SAAS 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
Kentuckys Sobriety Treatment And Recovery Team (START) as a catalyst for change
Achieving key SA and Child Welfare outcomes
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
6. 6 Kentucky START Model: A Catalyst for Change
7. START History and Sites START adapted from model developed in Cleveland in mid 1990s 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 familys 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:
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
Dont Jump to Conclusions
28. 28 Challenge in Evaluation Complex 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) werent 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 doesnt automatically make for collaboration
It cant make child welfare refer to your agency
Even contractual requirements cant 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
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