2.7 intensive service models for families and youth
DESCRIPTION
2.7 Intensive Service Models for Families and Youth Speaker: Dr. Judith Samuels Some families and youth benefit from more intensive and long-lasting supportive services to help them successfully transition out of homelessness and achieve housing stability. This workshop will focus on evidence-based service models, including Critical Time Intervention (CTI) and “wrap around”, and how homeless service providers are adapting these service models to get better outcomes for homeless and at-risk families and young adults.TRANSCRIPT
INTENSIVE SERVICE MODELS FOR FAMILIES AND YOUTH
FAMILY CRITICAL TIME INTERVENTION(FCTI)
February 9, 2012
Los Angeles, California
Research Scientist, The Nathan S. Kline Institute for Psychiatric ResearchResearch Professor, New York University, Department of Child PsychiatryAsst Professor, New York University, Wagner Graduate School of Public ServicePrincipal, SP3 Innovations
Judith Samuels, PhD
What I will cover:
Original Critical Time Intervention model Family adaptation (FCTI): philosophy FCTI Research How the model works Core Components Other work with CTI
CTI Basics
Time-limited Evidence base Increases continuity of care: from
homeless to housed Flexible to meet varying needs of
heterogeneous population Recovery oriented
Why CTI ???
People in multiple systems, multiple situations, often transitioning From homeless to housing From hospital to home From residential treatment program to
home From prison to community From foster care to independence
What is the critical time?
5
Prevention of Homelessness Among Individuals with Mental
IllnessElie Valencia, JD, MA
Ezra Susser, MD, DrPHAlan Felix, MD
NY Presbyterian HospitalDepartment of Psychiatry
The CTI Clinical Trial (1990-94)
Staying Housed N=2,937
Lipton, F. R., Siegel, C., Hannigan, A., Samuels, J., & Baker, S. (2000). Tenure in supportive housing for homeless persons with severe mental illness. Psychiatric Services 51, 479-486.
Why don’t people “survive?” Multiple complex needs Need for supportive relationships Fragmented service systems Lack of continuity of care
RESULTS Recidivism to:
Homelessness Prison Hospital Substance Abuse
Program/Intervention Process: Critical Time Intervention
Time-limited (9-month) case management
Titrated, 3 stages Focused team approach with aim
of reducing recurrent homelessness
Continuity of care Starts before transition takes place
Program/Intervention Process: Critical Time Intervention
Practices Employed - motivational interviewing - harm reduction
Clinical Interventions Mental Health Treatment Compliance Substance Abuse Services Money Management Prevention of Housing-Related Crises Family Psychoeducation Skills Training
Stages of CTI
Transition Months 1-3 Provide specializedsupport. Implementtransition plan
Try Out Months 4-7 Facilitate and testclient’s problem-solving skills
Transfer of Care Months 8-9 Terminate CTIservices with supportnetwork safely inplace
Flexibility of CTI Model
Designed to meet the individual’s needs. This increases cost-effectiveness and maximizes number of individuals served.
Services may be direct and assertive AND/OR maximize linkage to community resources.
Services aim to increase autonomy, self-care, and recovery.
Family CTI (FCTI) Over-arching Philosophy of Approach
comprehensive assessment of the homeless family, but does not assume the complex psychosocial problems of the family are the cause of homelessness
emphasizes that lack of affordable housing is the most important factor causing family homelessness
in some cases, problems arise out of homelessness and poverty, in other cases they merely co-exist
for some families, psychiatric disorders, substance abuse, and an array of psychosocial stressors may be contributing factors to the family’s homelessness
other economic factors contribute, such as the job market and accessibility of entitlements
once a family becomes homeless, any combination of the areas of need may serve to hinder progress into stable community living
intervention should target those problems and needs of the family that are most closely linked to persistent homelessness.
Figure 5-2. Model Program: Critical Time Intervention with Homeless Families
Program Family Critical Time Intervention model (FCTI). The program is jointly funded by NIMH and the Center for Mental Health Services/Center for Substance Abuse Treatment Homeless Families Program.
Goal To apply effective, time-limited, and intensive intervention strategies to provide mental health and substance abuse treatment, trauma recovery, housing, support, and family preservation services to homeless mothers with mental illnesses and substance use disorders who are caring for their dependent children.
Features The Critical Time Intervention model (CTI) was developed in New York City as a program to increase housing stability for persons with severe mental illnesses and long-term histories of homelessness. Its principle components are rapid placement in transitional housing, fidelity to a Critical Time Intervention CTI model for families (i.e., provision of an intensive, 9-month case management intervention, with mental health and substance use treatments), a focused team approach to service delivery, with the aim of reducing homelessness, and brokering and monitoring the appropriate support arrangements to ensure continuity of care.
Research:Westchester Families First
Randomized trial Family Critical Time Intervention (FCTI) with
rapid re-housing Vs. services/system as usual Baseline interview, 3, 9,15,24 month follow-up
Targets homeless families, singles moms w/mental illness and/or substance abuse
Challenges “housing readiness” criteria RAPID RE-HOUSING Housing is SCATTER SITE
Research:CTI for Homeless Families
Target Population Single Female Headed Households Children Under 18 Literally Homeless Mental Health and/or Substance Abuse
Problem High prevalence of:
Trauma history (abuse, separation) Low education Poor work history Health problems Unstable housing history
Research:CTI for Homeless Families
SAMHSA funding for “parent” study NIMH funding for children study Intervention program funded by State of NY Housing funded by HUD and Westchester County Random assignment:
100 families CTI, 123 families in control group No differences between groups at baseline
Outcomes: CTI families have less time homeless Children have better school and mental health outcomes
Family CTI Features
Strengthens ties to services, family, friends
Provides emotional and practical support Time-limited Limited goals Simple and adaptable Provide STRUCTURE to case management
Stages of Family CTI
0-3 Months: Transition to the Community
4-6 Months: Practicing Phase
7-9 Months: Transfer of Care
Stage 1: Transition to the Community
Much of this work was done in shelter This stage may be longer while securing
housing Intensive, assertive outreach-- Develop linkages to
community resources, evaluate and build living skills This stage is more complex for families as
children’s needs are also addressed Provide direct services when needed\
Psychiatist/psychologist meets weekly with CTI workers and consumers
Visit at least weekly More intensive while in shelter
Stage 2:Practicing Phase
Solidify linkages to community resources This includes schools, TANF workers, food
pantries, religious/spiritual resources Promote independent living skills
Includes family resources assessment and plans
Observe and test current plan Develop long-term plan Less frequent visits, more phone follow-up
Stage 3: Transfer of Care
Fine tuning of linkages
Higher level skills training (employment, education, social skills)
Termination with the client
Diagram of FCTI Model
PHASE 1
PHASE 3
PHASE 2
PRE-FCTI
3 months 3 months3 months
- Screening
- Referral - Engagement
- Intake
-Assessment
- Housing
- In vivo
Assessment
-Intervention
Assessment
-Fine tuning
-Less contact
Guidelines for Effective CommunicationActive & Focused, Supporting & Empathetic, Flexible but
Consistent,Fostering autonomy while remaining available
What Makes FCTI Different?
Highly Structured Model Continuity of assistance
From shelter to housing Focus on Cause of Housing Instability Time limited
Although a safety net is recommended High Level Clinical Support Motivational Interviewing Titrated model – intensity lowered over time CTI is an EBP
MODEL COMPONENT:Continuity of Assistance
From shelter to new home FCTI work begins shelter entry Intake/assessment Building relationship through Motivational
Interviewing Service plan based on mom’s goals Connections to community providers Support during move back to community
MODEL COMPONENT:Intensive Clinical Support
Does not replace case work supervisor Can be part time Supports team Provides indirect and direct care Opportunity for staff to increase
knowledge Can help ensure model fidelity
MODEL COMPONENT:Intensive Time Limited – 9 months
Many case work models are much longer Until family is “ready” Can foster dependence
Many families have more strengths than we think “survival” rate is very high
Allows for more families to be service We stress the time limit from day so
everyone is productive
MODEL COMPONENT:Titrated Model – 3 stages
Allows for uneven case load 12 cases: 4 stage 1, 4 stage 2, 4 stage 3
Forces case worker to move family toward discharge
Forces family to move toward discharge Reinforces strengths Reinforces “housing first” goal
Additional adaptations:
Young Families Model Emphasis on child development, baby care Evaluated in pilot study
Youth Aging Out of Foster Care Longer model Emphasis on life skills
Families leaving residential treatment
And more…
Current dissemination work: US Veterans Administration: homeless
veteran families (SSVF program) NY City: Home to Stay City of Ottawa, Canada UMOM, Arizona
Training Guide: Ready in Summer 2012 Training methods: on-site, distance led
Judith Samuels, PhD
For more information contact me:
Visit the CTI website:www.criticaltime.org