indicated prevention bridging the gap

Harris & Ryan Indicated Prevention

Journal of Psychoactive Drugs 277 SARCSupplement6,September2010

Indicated Prevention: Bridging the Gap, One Person at a Time

WilliamW.Harris,B.S.,C.A.D.C.II*&JanRyan,M.A.**

Abstract—In2007,RiversideCounty,California,afteridentifyingagapbetweenthesubstanceabusepreventionandtreatmentservicesitofferedtoindividuals,developedtheIndividualPreventionServices(IPS) program to fill that gap. Over the past two years, the IPS program has provided individualized preventionservicesonaone-on-onebasisatallsevenofthecounty’ssubstanceabusetreatmentclinics.TheIPSprogramisprovidedtothoseindividualswhoareathighestriskfordevelopingsubstanceabuserelatedproblems,i.e.,thoseindividualswhohavesomehistoryofsubstanceuse/misuse,buthavenotyetreachedapointwheretreatmentisindicated.Thisunique“onepersonatatime”preventionserviceis provided at no cost to individuals in all age groups (from age 12 to senior citizens) and is based, in part,onalocalstudentassistancemodelthatoffersover20yearsofprovenresults.

Keywords—briefintervention,BriefRiskReductionInterviewandInterventionModel(BRRIIM),Continuum of Services System Re-Engineering (COSSR) Task Force, indicated prevention, prevention serviceagreement

*PreventionServicesCoordinator,RiversideCountyDepartmentofMentalHealth,SubstanceAbuseProgram,IndividualPreventionServices(IPS)Program,Riverside,CA. **PreventionConsultant,RedleafResourcesConsultingandTraining,PalmSprings,CA. PleaseaddresscorrespondenceandreprintrequeststoWilliamHarris,RiversideCountyDepartmentofMentalHealth,SubstanceAbuseProgram,IndividualPreventionServicesProgram,3525PresleyAvenue,Riverside,CA92507;email:[email protected];phone:(951)782-2400;fax:(951)682-3576.

Filling the gap in the continuum of services between substanceabusepreventionservicesandtreatmentserviceshasalwaysbeenchallenging.This is especially true inacounty-operated substance abuse services setting wheretreatment and prevention funding come from differentsources and fiscal accountability requires strict separation of funding for theprovisionof treatment andpreventionservices.Additionally, providing prevention services to

individualsisanewconceptformostsubstanceabusepro-gramsandcancreatesoperationalchallengesinareassuchas funding, space, and staffing, and the programmatic chal-lengeofdesigningareferralprocess,intervention,anddatacollectionplan.Althoughthistypeofservicehastypicallyonlybeenseeninschool-basedStudentAssistanceProgramsorcorporateEmployeeAssistancePrograms,theRiversideCountyPreventionProgramviewedthesechallengesasanopportunity to significantly increase access to publicly-fund-edpreventionservicesforindividuals.Moreover,sourcesofnewfundingforinnovativeprogramsarehardtocomebyand,whentheyareavailable,accesstothemisextremelycompetitive. Therefore, when designing a service to fill the gapbetweenpreventionandtreatmentservices,thecriticaloverall challenge is to build a sustainable system usingexistingresources.



TheRiversideCountyDepartmentofMentalHealth– Substance Abuse Program (DOMH-SAP) met both the operational and programmatic challenges with its newlydevelopedIndividualPreventionServices(IPS)program.Thegoalwastoidentifyindividualswhotraditionallyfellinthe“gap”betweenpreventionandtreatment.Preventionser-viceswereco-locatedatexistingcounty-operatedsubstanceabuseclinics,whichhadfunding,space,andstaffmembers.Usingextantreferralprocesses,individualsareoffereda90-minuteinterviewcalledtheBriefRiskReductionInterviewandInterventionModel(BRRIIM;developedbyJanRyanandJimRothblatt,RedleafResources).Duringtheinterview,theparticipant’sinternalandexternalstrengths,resources,and needs are identified to create a personalized Prevention ServicesAgreementforfurthereducationandsupport.TwoCenterforSubstanceAbusePrevention(CSAP)strategies,Problem Identification/Referral and Education (Federal Register1993),meettheneedsofthepopulationofindividu-alsathighriskforsubstanceabuseandrelatedproblems.Theentireprocessisbasedoncognitivebehavioraltheoryandcombinestheevidence-basedpracticesofmotivationalinterviewing,riskandprotectivefactors,stagesofchange,and screening and brief intervention.With the supportandassistancefromtheStateofCaliforniaDepartmentofAlcoholandDrugPrograms (ADP)and the state-funded CommunityPreventionInitiative,andwithouttheadditionofanynewfunding,RiversideCountywasabletostrengthentheircontinuumofservicesothatindividualscouldreceivethescreeningandeducationtheyneededtoreducetheharmcausedbytheirsubstanceabuseandrelatedproblems.

BACKGROUND

Understanding Basic Prevention Funding, Populations, and Strategies Understanding the county’s size and basic funding formula was the first step to comprehending just howimportant itwas tomanageavailableprevention fundingcarefully.RiversideCounty,locatedinSouthernCalifornia,isthefourthlargestcountyinCaliforniainbothareaandpopulation,withanestimatedpopulationof2.1million(U.S.Census Bureau 2009).The Riverside County SubstanceAbuseProgram,underthedirectionoftheRiversideCountyDepartmentofMentalHealth,has,since1992,receivedalargeportion(currentlytwothirds)ofitssubstanceabuseprevention and treatment (SAPT) program funding fromthe federal government’s SubstanceAbuse and MentalHealthServicesAdministration(SAMHSA)intheformofaSAPTblockgrant.Twentypercentofthefundsreceivedthroughthegrantaremandatedforpreventionstrategies.The remaindermaybeused for treatmentorprevention.Of greater importance, the amount of treatment dollars releasedisproportionatelytiedtotheamountofavailableprevention dollars actually utilized. Therefore, the way that

alargecountylikeRiversidemanagesthepreventionfundsdirectlyimpactsavailabilityoftreatmentfunds. Thenextstepistodevelopanunderstandingofhowthefederalguidelineshaveimprovedpreventiondesignandidentified gaps in service.From the date of its establishment throughthepresent,SAMHSA’sCenterforSubstanceAbusePrevention(CSAP)directedthatanypreventionstrategiesdevelopedbycountiessuchasRiversideCountyconformto one of the following six categories (Federal Register 1993):

•InformationDissemination,•Education,•Problem Identification and Referral,•Community-basedProcesses,•AlternativeActivities•EnvironmentalPrevention.

Duringthistime,fundingforproviderstaskedwithimple-mentingthesesixCSAP-approvedstrategieswaslimitedtointerventionsdirectedatthepopulationingeneralandnotindividualsathighrisk. In2006,theCaliforniaDepartmentofAlcoholandDrugPrograms(CAADP)establishedtheContinuumofServicesSystem Re-Engineering (COSSR) Task Force to provide recommendationstothedepartmentonre-engineeringthesystem of alcohol and other drug (AOD) prevention, treat-ment,and recoveryservices inCalifornia. Basedon therecommendationsofthistaskforce,theStateofCaliforniaembraced the Institute of Medicine’s (IOM 1994) three targetedcategoriesofsubstanceabusepreventionpopula-tions,asdefinedbyGordon(1987),andincludedthemintheirrecommendedcontinuumofservices(CAADP2006).

•Universal population:Thegeneralpublicoraseg-mentoftheentirepopulationwithaverageprobabilityofdevelopingadisorder,risk,orcondition.

•Selective population: Specific subpopulations whose risk of a disorder is significantly higher than average, eitherimminentlyoroveralifetime.

•Indicated population: Identified individuals who haveminimalbutdetectablesignsorsymptomssug-gestingadisorder.

SAMSHA first proposed utilizing these guidelines in December 2002 (Federal Register 2002).Now, for the first time,moniesobtainedbythecountythroughtheSAPTblockgrantwereavailableforthedevelopmentofsubstanceabusepreventionstrategiesattheindividuallevel. In 2005, the CA ADP notified the substance abuse pro-gramsofall58countiesinCaliforniaregardingSAMHSA’sintent to introduce the use of the Strategic PreventionFramework (SPF). The SPF provided a systematic approach toevidence-based,outcome-orientedpreventionplanningatthecountylevel.Localcountiesweredirectedtosubmittheir SPF documents for ADP approval by mid-July 2007. The SPF process was an extraordinary opportunity to use the



new IOM prevention populations to define who is served, to implement all six CSAP-defined strategies to define howtheyareserved,andtoshowhowthenewlydesignedweb-based data system, California Outcomes Measurement Service for Prevention (CalOMS Prevention), improves capacitytotrackoutcomes.TheSPF process allowed the SubstanceAbusePreventionProgramofRiversideCountytoevaluateitsexistingcontinuumofservicemodelandtheabilityofthatmodeltoservetheneedsofthethreeCSAP/ADP-identified population categories.

Problem Solving: Using Basic Prevention Tools to Define the Problem and Solution As a result of the SPF process, the county ascertained thatadequatepreventionprogramsandcountyandcontractorserviceswereinplacetomeettheneedsofthe“universal”populationandasmallsegmentofthe“selective”population.However,communityinputdeterminedthatthe“indicated”population,thepopulationofindividualswhosebehaviorputthemathighriskforproblemswithalcoholandotherdruguse (IOM 1994), was unserved. More specifically, the county determinedthatnoprevention/interventionservicesexistedtomeettheneedsofindividualscaughtinthegapbetweenitsexistingpreventionandtreatmentservices,i.e.,thoseindi-vidualswho,thoughtheywereexperiencingsubstanceusageproblems,hadnotyetreachedalevelofsubstanceabuseseveritywherediagnosisand/or treatmentwas indicated.Inshort,nofundedprogramswereavailableforindividualswhoseseverityofsubstanceabuseproblemsdidnotrisetothelevelofareferralforadiagnosticassessment.Individu-alshadtogetworse—becomefullyinvolvedinsubstanceabuseand/oraddiction—tomeetthecriteriaestablishedforreceivingthefarmorecostlytreatmentservicesavailable.Becausetherewerenootheroptionsavailable,oftenwhentheseindividualspresentedatRiverside’ssubstanceabuseclinicsforservices,theywereeitherturnedawayorwereenrolledina16-weektreatmentprogramthatwasinappro-priate for theirneeds.Bothwereunacceptable solutions;however, the new IOM definitions addressed this specific gap in services and, for the first time, clearly identified these persons who needed service and defined the services they neededasfallingwithinthepreventionarea.

Challenges Therewere twosetsof challenges in instituting ser-vicesfortheindicatedpopulation:operationalchallengesandprogrammaticchallenges.Theoperationalchallengesrequiredusingexistingresourcestoexpandservices,whichmeant utilizing extant funding, space, and staff. Program-maticchallengesincludedfollowingthecurrentstateandfederalguidelines forprevention,whichmeantusing theexistingreferralprocess,thenofferinganevidence-basedandculturallysensitivepreventionintervention,follow-up,andevaluation.

Operational Challenges: Funding, Space, and Staffing Solutions Funding.Wheninitiallyassessingthepossibilityofbe-ginninganindicatedorindividualpreventionprogramwithinRiverside County DOMH-SAP, one of the first questions that arosewashowtheprogramwastobefunded.Whenfundingfor2006(theyearprior to thisprogram’s inception)wasanalyzed, it was found that a total of approximately $670,000 peryearwasbeingspentatthesevencounty-operatedsub-stanceabuseclinicsonpreventionservices.ThisamountwasspentprimarilyontheCSAPstrategiesofInformationDisseminationandCommunity-basedProcess.Therewerealso six private contractors throughout the county whowere funded for a total of $690,000 providing the same preventionservicesastheclinicsalongwithEnvironmentalPrevention. In moving through the SPF process at that time, itbecameapparentthatthisduplicationofservicesbetweencontractorsandclinicswasunnecessary.Withcommunityinput through the SPF process, it was determined that the contractorswerewellequippedtoprovideInformationDis-semination,Community-basedProcess,andEnvironmentalPrevention strategies sufficient to meet the needs of the entire county. This meant that the $670,000 that had been usedatthecounty-operatedsubstanceabuseclinicscouldthenbedivertedtothenewlycreatedIndividualPreventionServices(IPS)program.Thisprovidedthefundingnecessarytooperatethisprogram. Space.Thecountydeterminedthatco-locatingpreven-tionservicesatitssevenexistingsubstanceabusetreatmentclinicswasthebestapproachtoidentifyingthoseindividu-alsinthisnewlydesignated“indicatedpopulation.”Theseclinics, which are spread geographically throughout thecounty, were in constant receipt of individuals referredforsubstanceabusetreatmentbylawenforcement,publichealth,schools,andfamilies.Historically,itwasinthesesamesevenclinicsthatthe“goodnews–badnews”wasbeingdelivered.Individualsreferredforservicesweregiventhe“goodnews”thattheywerenotyetatapointintheirsubstanceusewheretreatmentwasindicated,andthe“badnews”thatnofundingexistedtohelpthemreducetheharmcausedbytheirsubstanceabuseortoavoidcontinuingtheirusetothepointofbecomingaddicted.Withtheincorpora-tionoftheindicated(individual)populationintothefundedcontinuumofservicesin2007,RiversideCounty’ssevencountytreatmentclinicswerethenabletoofferpreventionservicestotheseindividuals. Staff.Four certified substance abuse counselors who werecurrentlyemployedatvariouscountysubstanceabuseclinicswereassignedtoserveaspreventionspecialistsattheclinics.Theseindividualswereselectedbasedontheirinterestintheprogram,andontheirmeritassuccessfulandpersonablesubstanceabusecounselors.Thefourindividualsunderwent specialized training for this work as described laterinthisarticle.Theyinitiallyprovidedservicesatsixofthecounty’ssevensubstanceabuseclinics.



Programmatic Challenge: Separating Prevention Screening From Treatment Assessment Relevantcurrentstateandfederalguidelinesforpreven-tionofferedthefoundationfordesigningareferralprocessfor the indicated, or individualized, prevention service, now called the Individual Program Service (IPS). By definition, indicatedpreventiontargetsindividualswhohaveminimalbut detectable signs or symptoms suggesting a disorder(Gordon1987).Historically,boththereferralagenciesandthereferredindividualsexpectedoneservicefromthecountysubstance abuse clinic—treatment. The first meeting with the clientwascalledmanynames:intake,screening/assessment,ordiagnosis.Thetypicalresultwasadiagnosisandreferraltoa levelof treatment, theonlyservicethenavailabletoindividuals. With state-funded Community Prevention Institutetraining and technical assistance, Riverside County stafflearnedtoseparatescreening—theprocessusedtodetermineif education can reverse behavior, fromassessment—theprocessusedtodetermineadiagnosisfortreatment.Inthepast,allindividualswhopresentedthemselvesforservicesat the clinics filled out an application form and were then directedtoatreatmentprofessionalforfurtherdiagnosticassessment. With the new protocol, individuals still fill out the application form; however, the form is first reviewed by staffandtheindividualisthenmovedinoneoftwodirec-tions. Ifontheapplicationformtheindividualindicatesthattheyhadapriortreatmentepisode(e.g.,apreviousdiagno-sisofasubstanceuse/abusedisorder)oriftheyarebeingmandatedfortreatmentfromtheStateofCaliforniaParoleeServicesNetwork(PSN),Prop.36(the2000Californialawmandatingtreatmentinlieuofjailfornonviolentdrugpos-sessionoffenders),orChildProtectiveServices/DepartmentofPublicSocialServices,thentheyarescheduledwithatreatmentprofessionalfordiagnosticassessment.Allotherindividuals are moved through Prevention Services forscreening. Anotherchallenge that thecountyfacedwas thede-velopmentofapreventioninterventionthatwasgroundedin evidence-based practice. The federal definitions of the CSAP strategies of Problem Identification/Referral and Education provided the foundation for the intervention,follow-up,andevaluation.Thegoalofaprevention-focusedscreening process is to see if the individual would benefit fromeducation.Unliketreatment-basedtoolssuchastheAddictionSeverityIndex(ASI),whicharediseasefocused,andassuchareusedtoprovidetreatmentclinicianswithanassessmentoftheseverityofaclient’sillness,thetoolthePreventionSpecialistsneededwasonethatwouldhelpthemquicklyidentifytheindividual’sstrengthsandinternalandexternalresources,withtheultimategoalofreducingharmbyaddressinghigh-riskbehaviors. RiversideCountyhadanexistingmodelofindividualpreventionservicedeliverywithmanyyearsofsuccessand

documentedevidencedemonstratingthatasystemcanpre-ventsubstanceabuseandreduceriskbehaviorsonepersonatatime(Andersonetal.2007;Roberts2005).AfederalSafeSchools/HealthyStudentsInitiativegrant,fundedfrom2002through2005,createdasuccessfulcollaborationbetweenthe DOMH-SAP, members of the law enforcement com-munity, the Riverside County Office of Education, and the Desert Sands Unified School District to demonstrate that a componentoftheDesertSandsStudentAssistanceProgramcouldbereplicatedineightschooldistrictstobuildaccesstopreventionforover100,000students.Aninnovativeteamin theDesertSandsDistrict hadusedbasicmotivationalinterviewing research to create a structured interview towork with youth/families as the first step of their preven-tion services. This was the first large demonstration of the effectiveness of the “family conference,” an individualized preventionserviceusingaprevention-basedscreeningtool,nowcalledtheBriefRiskReductionInterviewandInterven-tionModelorBRRIIM(Andersonetal.2007;Rolfeetal.2004). AscriticalpartnersintheDesertSandsprogram,Riv-erside County DOMH-SAP staff wondered whether the successes realized in the Safe Schools/Healthy Students Initiative program could be replicated on a county-widebasis. DOMH-SAP recognized that with modification, the individualpreventionmodelcouldmeetmanyof thechallengesitfacedinthedevelopmentofapreventionin-terventionattheindividual,orindicated,level.Accordingly,theCountyofRiversidecontractedwiththedevelopersoftheBRRIIMprocessfortrainingandassistancetomodifytheDesertSandsprogram,withthegoalofincorporatingthemodified program into the county’s continuum of service. Theworkproductofthateffortbecamethecounty’snewIndividual Prevention Service (IPS) program (see Figure 1). Initially,thisservicewasofferedatsixofthecounty’ssevensubstanceabuseclinics.Asmentionedabove, fourcertified substance abuse counselors were selected as the initialPreventionSpecialistswhowouldbeprovidingtheservicesatthesixclinics.In2007,theseventhcountyclinicbeganprovidingtheserviceandtherearenowsevenPreven-tionSpecialists,eachdedicatedtoaparticularclinic,whoprovidethisservicethroughoutthecounty.EachPreventionSpecialistcompleted40hoursofinitialtrainingundertheguidanceofoneorbothoftheco-developersofBRRIIM.Additionally,theseindividualscontinuetoreceivemonthlytraining updates to maintain model fidelity and integrity and todiscussanyissuesorconcernswiththeirpeers.

CSAP Strategy: Problem Identification and Referral using the BRRIIM Interview TheBRRIIMinterviewisthecorecomponentofthepreventioninterventionduringtheinitialengagementwiththe individual or “participant,” as they are known. This first engagement utilizes the CSAP strategy of Problem Identi-fication and Referral. This strategy aims to identify those



FIGURE 1Riverside County, CA, Individual Prevention Services (IPS) Flow



individualswhohaveindulgedinillegal/age-inappropriateuse of tobacco or alcohol or in first use of illicit drugs in order toassesswhether theirbehaviorcanbereversedthrougheducation. The individual’s family members and/or signifi-cant others are encouraged to attend the first meeting with thePreventionSpecialist.Becausefamilymembersareofteninvolved,thisinitialmeetingissometimesreferredtoasthe“familyconference.”Iftheparticipantisanadolescent,theirparent(s)orguardian(s)maybepresent.Iftheparticipantisan adult, their spouse or other significant individuals may be present,orifasenior,acaregivercanbepresent.Becausetheoriginalmodelwasbasedononeusedwithastudentpopulationwithinaschoolorschooldistrictsetting,somechangeshadtobemadetoaccommodatethechangetoacounty clinic setting. The first change was the creation of twoseparateinterviewmodels:anadolescent/youngadultmodelusedforparticipantsundertheageof25,andanadultmodelusedforthoseovertheageof25.Appointmentsforadolescentsseekingservicesareusuallymadein the lateafternoontimeslotstoallowfortheindividualtobeseenafterschoolhasbeendismissed. TheBRRIIMinterviewisaneutralscreeningprocessinwhichthePreventionSpecialistmakesuseofthestructuredBRRIIMformattoidentifypotentialstrengths,concerns,andneedsintheparticipant’slife;itisessentiallyathree-stagemotivationalinterviewprocessthattakesabout90minutes.As noted above, during the first stage of the interview, both theparticipantand,wheneverpossible,familymembersarepresent.ItisduringthisstagethatthePreventionSpecialistestablishesinitialrapportwiththeparticipantandthefamilymembers.ThePreventionSpecialistbeginsananalysisoftheparticipant’sriskandprotectivefactorsthroughtheuseofquestionsinastructuredinterviewformat.Thequestionscenter on school/educational (emphasis for adolescents)andworkhistory(emphasisforadults);familydynamics,includinganyhistoryoffamilyviolenceand/oraddictionand treatment formentalhealth issuesaswellascurrenthomeclimate;social/peersupport;andcurrent,recent,orongoingstressorsintheparticipant’slife.Thesequestionsaim to identify assets in the participant’s life that couldhelpthemmeettheirdesiredgoals,aswellasidentifyandaddress identified needs and concerns. At the conclusion of this portion of the process, the participant’s significant familymembersareaskedtoleavetheinterviewtemporar-ilywhilethePreventionSpecialistcontinuestheinterviewone-on-onewiththeparticipant. During this second stage of the interview, the Pre-vention Specialist addresses issues with the participantincluding drug use history, sexual history, criminal his-tory,angerandotheremotionalissues,personalgoalsandaspirations,andanyotherpossiblyseriousconcerns.Nothavingtheparticipant’sfamilypresentduringthispartofthe interview allows the participant to talk freely aboutsensitiveissuesandtendstofurtherbuildtrustbetweenthePreventionSpecialistandtheparticipant.Itisduringthis

stageoftheinterviewthatthePreventionSpecialistidenti-fies which “stage,” using the Stages of Change model, the participant is at with regard to addressing identified needs andconcerns.Ifduringthisstage,theparticipantindicatesa significant level of substance abuse involvement, it is commonforthePreventionSpecialisttoadministeroneormoreofthestandardscreeninginstrumentsforsubstanceabuse (Project Cork 2004). Most commonly, the CRAFFT is usedwithadolescentsandtheMichiganAlcoholScreeningTest(MAST)and/orDrugAbuseScreeningTest(DAST)isusedwithadults(ProjectCork2004).Thisadditionaldataassists the Prevention Specialist once the planning stageoftheinterviewisreached.Uponcompletionofthisstageof the interview, the familymembersareasked to rejointheinterview.Insummary,BRRIIMisbasedoncognitivebehavioral theory and is organized as a structured motiva-tionalinterviewthatusesopenandclosedquestions.Thesequestionscreateadialoguethatrevealsriskandprotectivefactors,impartstheparticipant’sreadinesstochangeusingtheStagesofChangeModel,andhelpsindesigningabriefinterventionthatisuniquetothatindividual. In the final stage of the interview, a plan of action is formulatedwithinputfromallpartiespresent.IfthePre-vention Specialist feels that the participant demonstratesexcessiveriskfactors,excessivedrugoralcoholuse,oralack of sufficient assets to build upon, then the Prevention Specialistwillrecommendthattheparticipantbereferredtoasubstanceabusetreatmentprofessionalorothermentalhealthprofessionalforfurtherdiagnosticassessment.Thisreferralismadewithinthesameclinicoftenonthesameday. On the other hand, if it appears that the participant’s substance abuse history is such that a brief interventionthrough education may benefit them and they have personal assetsintheirlifethatwouldsupportthisapproach,theIPSprocesscontinues.

CSAP Strategy: Education - Prevention Service Agreement for Prevention Education/Support. During this third stage of theBRRIIM interview process, the participant, significant familymembers,andthePreventionSpecialistenter intodevelopingaPreventionServiceAgreement(PSA),throughwhichaccordisreachedinthreeareas:

1.Whattheparticipantiswillingtodo,2.WhatthePreventionSpecialistiswillingtodo,and,

ifpresent,3. What the participant’s family or significant others are

willingtodo.In addition, if the Prevention Specialist has identified needs andconcernsnotaddressedbytheparticipantinthePSA,thePreventionSpecialistmaymakecertainrecommenda-tionstotheparticipantaswellastotheirfamily.ThePSAs,which are individualized and are not agenda driven, are built upon participant willingness to make identified behavioral changes. The agreement is formalized in a document that



is signed by all parties: the participant, the participant’sfamilymember(s),and thePreventionSpecialist.Acopyofthedocumentisprovidedtotheparticipantandfamilymember. Aspartofthisprocess,theparticipantandPreventionSpecialist determine if additional meetings are required.Ifindicated,theparticipantandPreventionSpecialistwillschedule subsequent meetings until both agree that theparticipant’s goals have been met. These meetings utilize theCSAPstrategyofEducationtoprovidetheparticipantwith informationon theharmfuleffectsofdrugsandal-cohol. During these additional sessions, the PreventionSpecialist will continue to utilize motivational interviewing techniquesalongwithexercisesthataddressanyparticipantambivalenceandassisttheparticipantinmovingthroughthestagesofchange.ThePreventionSpecialistmayalsointroduceactivitiesdrawnfromcognitivebehavioraltherapyas“homework”toaddressself-defeatingbehaviororothertypes of flawed thinking patterns that may be present. It is duringtheseadditionalsessionsthatthePreventionSpecial-ist encourages the participant to utilize the protective factors and assets identified during the BRRIIM interview to help facilitatethechangesthattheyarelookingfor.ThePSAisaniterativedocumentandprocess.Iftheinitialplan(PlanA)doesnotseemtomeettheneedsoftheparticipant,thenasecondplaniscreated(PlanB),and, ifneeded,a third(PlanC),etc.untiltheneedsoftheparticipanthavebeenmet.Currentdatashowsthatonaverage,participantsmeetforanadditional3.4meetings.TheparticipantandPreven-tionSpecialistdeterminewhentheinterventioniscompletebasedonthePreventionSpecialist’sandtheparticipant’ssatisfactionthatparticipantgoalshavebeenmetasindicatedinthePSA(s).Thelastface-to-facemeetingwiththePre-ventionSpecialistisfollowedupwithaphonecallwiththeparticipantaftertwoweeks.TheparticipantistoldatthistimethattheyarealwayswelcometocontactthePreventionSpecialistinthefuturewhenevertheyfeelthereisaneed. There have been several instances where, after theimplementationofseveralPreventionServiceAgreements,theparticipanthasfailedtomakeprogresstowardmeetingsetgoals.Insuchinstances,thePreventionSpecialistmayrecommendthattheparticipantbereferredtoatreatmentprofessionalwithintheclinicforadiagnosticassessment. Additionally, if the family requests additional timewiththePreventionSpecialistaftertheinitialinterview,ar-rangementsforsucharemade.Inthesefamilymeetings,noconfidential information about the participant is discussed, unlesstheparticipanthassignednecessaryreleaseforms.Thesemeetingsareonly intended to allow the family tobecomeanally in thepreventionprocessand toeducatethem,aswell. A note on cultural sensitivity should be made here.SinceRiversideCountyhasa largeHispanicpopulation,arrangementshavebeenmadetoprovideservicesinSpanishasneeded.SeveralofthePreventionSpecialistsarebilingual

and can provide direct services in Spanish. For the other Pre-ventionSpecialists,aninterpreteronstaffwithintheclinicisbroughtintotheinterviewandprovidestranslationservices.Insuchinstances,thePreventionServicesAgreementdocu-mentiscompletedanddeliveredinSpanishandinEnglish.ThisprocesshasbeensuccessfulandappearstomeettheneedsofthemonolingualHispanicpopulation.Alsoworthmentioningwithregardtoculturalsensitivity,theBRRIIMprocessfocusesontheindividualparticipantanditistheresponsibilityofthePreventionSpecialisttolearnfromtheparticipantand,wheneverpossible,theparticipant’sfamilymembers, the specific cultural elements that will best serve the participant as identified strengths in addressing their needsandconcerns. All demographic information on the participant andtheirfamily,aswellasinformationontheservicesprovidedand time involved, is collected and entered into the confiden-tial CalOMS Prevention Data System. This is a web-based program that collects informationonprevention servicesthatareprovidedbyindividualsandagenciesthroughoutCalifornia.Thisdataisusedtoevaluateprocessoutcomesandtrackthedeliveryofservicesprovided.

RESULTS

During the first two years of the program’s implemen-tation, BRRIIM interviews or family conferences wereconductedfor1,158participants.Theaveragedurationofthese interviews was 1.8 hours. Of those, 692 (59.8%) were referred for diagnostic assessment and 466 (40.2%) were retainedintheIndividualPreventionService(IPS)programand entered into Prevention Service Agreements (PSAs). Of thoseparticipantsenteringintoPSAs,eachwasseenforanaverageof3.4additionalsessions;theaveragedurationofasessionwas1.6hours. Given the relative infancy (two fiscal years old) of the program, results are limited at this time. Furthermore, pastfundingresourcesdidnotallowforthecreationandmaintenanceofanextensivemultiyearfollow-upprogram.However, the county is gratified at the number of individu-alswhoenteredintoPSAsinthetwoyearsofitsexistence.Prior totheestablishmentof theIPSprogram,all466ofthese individuals would have either been turned awayfromthetreatmentclinicwithnoplanforsubstanceabuseprevention,orwouldhavebeen inappropriatelyadmittedtoa16-weekoutpatienttreatmentprogram.Thelatterwasmostoftenthecase—themajorityofindividualspresentingthemselvesforservicesexpectedatthattimetogettreat-ment,evenifitwasnotindicated.Thesavingstothecountysystemalonefromthese466individualsnotbeingadmittedtotreatmentisenoughtocallthisprogramasuccess.Withinthecountysystem,theaveragecosttoprovidea16-weekoutpatienttreatmentprogramtooneindividualisapproxi-mately $4,800. The average cost of one individual going through the prevention program is approximately $1,011.



This represents a savings of $3,789 per individual, or a total savings of $1,765,674 for the county treatment program in the first two years of this program. Additionally, input fromparticipants in their follow-upinterviewsregardingtheirsatisfactionwiththeservicesreceived has been overwhelmingly favorable; 95% of those interviewedindicatedthattheywouldseekpreventionser-vices again if needed, and 95% indicated that they would recommendtheseservicestoothers.Theappendixprovidesacasestoryasanexampleofhowthecounty’spreventionservicesoperate.

Ongoing Challenges RefinementoftheRe-EngineeredContinuum-of-Ser-viceApproach. ThoughthecountyhasmadeconsiderablestridestowardcreatingacontinuumofserviceconsistentwiththeCaliforniaADPcoreprinciples,leadershiprecog-nizes that there is much that remains to be done and we are challengedtoworkcloselywithourcommunityandagencypartnersaswebecomemoreaccustomedtotheinteractionsneededtoimplementasuccessfulcontinuumofservice. Programfidelity.MonthlygroupsupervisionkeepsPre-ventionSpecialistsfocusedondevelopingsolutionsbasedonindividualparticipant’sstrengths;itcanbeeasytoslipbackintoproblem-focusedthinking.Traininginevidence-basedpracticesreinforcedbysharingparticipant’ssuccessesservesasaconstantmotivationforthePreventionSpecialists. Earlyidentificationforself-referringparticipants.Ac-cesstoservicesacrossthecountyhasimproved,butsincemostreferralscomefromcountyagencies,individualswhomight benefit from the process may still be underserved. Therefore, educating the “universal” population remainsanimportantpartofthespectrumofprevention.Justasthepublichaslearnedthewarningsignsofstrokesandheartattacks, it is our hope that we can find ways to teach the general population the early warning signs of substanceabuse so that they will recognize those signs, know that helpisavailable,and,ifappropriate,self-refertooneofourclinics.

Next Steps Evaluation.TheCountyofRiversidehasreceivedfund-ingthatwillallowRiversideCountyPreventionServices toengageathirdpartytoconductathoroughevaluationoftheresults of the IPS program. In February 2010, the Riverside County Individual Prevention Services Program was therecipientofoneofthisyear’sServicetoScienceAwardsafterbeingnominatedby theStateofCaliforniaDepart-mentofAlcoholandDrugPrograms.ServicetoScienceisanationalinitiativefromtheUnitedStatesDepartmentofHealthandHumanServicessupportedbytheSAMHSA’sCenterforSubstanceAbusePrevention(CSAP).Thiswas

acompetitiveapplicationthathonorsnewandpromisinginterventions in the prevention field. As a result, Riverside CountyPreventionServices willbereceivingtechnicalas-sistanceinestablishinganevaluationprotocol,inthehopeofidentifyingoneormorepositivebehavioraloutcomes.Additionally,wewouldhopetheevaluationprocesswouldallowustodemonstrateevidenceofsuchoutcomesthroughaquasi-experimentaldesign. Datacollectionandreview.TheprogramdevelopersinRiversidewillcontinuetoworkcloselywiththestatestaffto improve the confidential tracking of individual service using the new California Outcomes Measurement Service for Prevention (CalOMS Prevention).

CONCLUSION

Riverside County’s project was initiated to fill a gap in thecontinuumofservicesforsubstanceabusewithtimely,seamlessservicedeliverybetweenpreventionandtreatmentprograms.Thecounty’sIndividualPreventionServicesstaffwantedtoimplementapreventionprogramthatofferedahopefulpathtothoseindividualswhoseinvolvementwithalcoholandotherdrugshadnotyetreachedthelevelwhereadiagnosisand/ortreatmentwasinorder.Thegoal,attheindividuallevel,andwiththehelpoftheparticipant,wastostoptheproblembeforeitprogressed.DespitetheambitiousaimofofferingtheIPScountywidethroughthesevencountysubstanceabuseclinics,theprojecthasmetandexceededourhighestofexpectations.Accesstoservicesisconsideredasuccessfortheparticipants,staff,andthesystem. Astheprogramwasimplemented,threelevelsofchangewereanticipated:

1. Individual level: an increase in each participant’saccesstoservices,

2.Staff level: an increase in the capacity of Preven-tion Specialist staff to individualize prevention services and their ability to work collaborativelywithtreatmentstafftocreateaseamlesscontinuumofservices.

3.Systemlevel:tointegrateaspectrumofpreventionintoanexpandedcontinuumofservices.

TheimplementationoftheIPSprocessinRiversideCountyhas created access to individualized prevention, built the staff commitment to fidelity through ongoing training, made significant progress toward the goal of offering a continuum of services that bridges the gap between prevention andtreatment,andimprovedcountystaff’sunderstandingandsupport of prevention.Taking a “one-person-at-a-time”approachtoprevention haseducatedeachlocation’steamofbothpreventionandtreatmentstaffandoursystempart-ners about how all the services benefit and improve when preventionisavailable.



REFERENCES

Anderson, M.B.; Crowley, J.F.; Hertzog, C.L. & Wagner, S. 2007, January. Help is Down the Hall: A Handbook on Student Assistance. Rockville,MD:SubstanceAbuseandMentalHealthServicesAdministration,CenterforSubstanceAbusePrevention.

CaliforniaDepartmentofAlcoholandDrugPrograms(CAADP).2006.Continuum of Services Re-Engineering Task Force: Phase I Report.Sacramento, CA: California Department ofAlcohol and DrugPrograms.

Federal Register. 2002. Volume 67, No. 247, December 24.Federal Register. 1993. Volume 58, No. 60, March 31.Gordon, R. 1987. An operational classification of disease prevention. In:

J.A.Steinberg&M.M.Silverman(Eds.)Preventing Mental Disorders.Rockville,MD:DepartmentofHealthandHumanServices.

Institute of Medicine (IOM). 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research.Washington, DC:NationalAcademyPress.

ProjectCork.2004.Project Cork Online, Clinical Tools, Screening Tests.Availableat:http://www.projectcork.org/clinical_tools/index.html.

Roberts, B. 2005. Background Briefing Paper #5: Student Assistance Programs (SAPs). Governor’s Prevention Advisory Council (GPAC) High Rate Underage Users Report.SantaRosa,CA:CommunityPreventionInitiative.

Rolfe,M.;Austin,G.;Rutherford,R.;Hendrick,S.;Seave,P.&Phillips,J.2004.High Rate Underage Users: Need and Promise of a School-Based Solution. Governor’s Prevention Advisory Council (GPAC) High Rate Underage Users Report.SantaRosa,CA:CommunityPreventionInitiative.

U.S. Census Bureau. 2009. State and County QuickFacts. Riverside County, CA, 2009.Available at: http://quickfacts.census.gov/qfd/states/06/06065.html.

APPENDIX One Individual’s Experience with the Evolving Continuum of Services in Riverside County: IPS Case Story

Provided by Pio Dingle, Prevention Specialist, Riverside County Substance Abuse Program

Theparentsofa15-year-oldHispanichighschoolsophomorewereconcernedabouthisdeclininggradepointaverage,lesstimespentathome, increasing tendencies to“talkback,”andrecentpositivedrugtestformarijuana.TheybroughttheirsonintotheSubstance Abuse Program office, where he was assessed and placed in the Adolescent Outpatient Group. I have both treatment and preventionassignmentsinourclinic,soinmyroleasthegroup’streatment facilitator, I noticed that the youth was consistentlyunabletointeractorrelateatthelevelofothergroupmembers.Idecidedtospeakwiththeparticipantaftergrouponedaytore-view his file and do a second diagnostic assessment. That second assessmentdidnotresultinadiagnosisindicatingareferralfortreatment. IinvitedthefamilyinforanAdolescentBRRIIMInterview.ThroughtheBRRIIMinterview,Ilearnedthattheyouthhadmademanypositivechangesalready,buthestillhadareasofhislifehewantedtoexplore.Wealsodiscoveredthatonethereasonshestruggledtostayalertinschool(otherthanhisinitialmarijuanausepriortohisinitialreferral),wasbecausetherewaslittleorno“buy-in”onhisparttowardthesubjectmatterbeingtaught.Schoolhad become unimportant except for his art classes. During the final stageoftheinterview,theparticipant,hisfamily,andIdevelopedhisPreventionServiceAgreementor“PlanA.” The participant was willing to: (1)continue toseemeforeightmorevisitsthroughtheconclusionofspringbreakbecausehefeltitwouldhelphimstayclean,(2)stayawakeinschooland

paybetterattention,(3)workwithmeonrefusalskillsbecausehewantedtofeelmorecomfortabletellinghispeershedidn’twanttododrugs,and(4)develophisinterestsinart(drawing,tattooing,etc.). The family was willing to:(1)participateduringtheinterven-tionasrequested,(2)continuetomonitortheyouth’sbehavior,(3)workoncommunication,and(4)drugtestifnecessary. As the provider: I researched the top five tattoo establish-mentsinSouthernCalifornia,locatedoneinSanDiego,andthenfoundlinkstoeachartistandhisorherbackground.Twoofthemostsought-afterartistshaddegreesingraphicartdesign.Isharedthisinformationwiththeparticipantand,asaresult,hebecameinterested in doing better in school, recognizing the importance of agoodoverallGPAtohelphimqualifyforpotentialscholarshipsto study graphic arts in college. When he realized the importance ofbetterapplyinghimselfinschool,andhadareasontodoso,hereportedhefounditeasiertoturndowndrugsofferedbyfriendsorotherteens. Follow-up:Itriedtofollow-upwiththeparticipantduringthesummer,butthefamilyphonehadbeendisconnected.However,in October of 2009, the participant personally stopped by to say hello and thank me. He said that due to financial problems within thefamily,theirphonehadbeendisconnectedfortwomonths.Healsosharedwithmethefactthathisfatherhadacceptedajobofferoutsideoftheareaandthefamilywasabouttomove.

indicated prevention bridging the gap

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