8/29/2011

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Welcome

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log located on the bottom half on your panel/dashboard.

A Program of theSubstance Abuse and Mental Health Services

AdministrationCenter for Substance Abuse Treatment

&the Administration on Children, Youth and Families

Children’s BureauOffice 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 RobinsonSandy RobinsonConsultantConsultant

Children and Family FuturesChildren and Family Futures

4 9 4 0 I r v i n e B l v d , S u i t e 2 0 2 , I r v i n e , C A 9 2 6 2 07 1 4 - 5 0 5 - 3 5 2 5 n c s a c w @ c f f u t u r e s . o r g

h t t p : / / w w w . n c s a c w . s a m h s a . g o v

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Agenda

• 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

Sometimes Child Welfare and Substance Abuse Treatment are Worlds Apart

Child W lf

Substance Abuse 

6

Welfare Treatment

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

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Improve the capacity of CWS to serve parents with substance use disorders

Increase collaboration between agencies

Ensure reasonable efforts

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Purpose Of Utilizing Substance Abuse Recovery Specialists

Decrease time to assess and enter treatment

Increase compliance with treatment

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Increase 12 month permanent placements

Increase family reunification rates

Decrease time in foster care

Roles and Responsibilities

Case management

Screening, assessment, referral, and engagement into Treatment

Support to parents while in treatment

C d t h i it (CT DE IL S t )

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Conduct home visits (CT, DE, IL, Sacramento)

Urine testing (CT, DE, IL, Sacramento, San Diego)

Consultation and Information sharing with CW and/or courts

Training to CW and potentially the court

Develop and implement substance abuse capacity building plans for CW (MA)

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Training and Supervision

Licensed/certified addiction counselor

Licensed clinical SW with addiction certification (CT)

Supervised by child welfare (CT, NH, WA)

Supervised by contracted service provider (IL, S t S Di )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)

Participates in cross training

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Employed by state, county CW agency, community-based AOD treatment agency, contracted service provider or Self-employed and contracted by CW

Location and Settings

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Area/regional/county/district CW offices (CT, DE, MA, NH, WA)Contracted service provider’s office, near to juvenile court (IL, Sacramento, San Diego)

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Underlying Values and Agreements

MOU or other agreement formally outlines joint values and principles for the program (Sacramento, WA)MOU or other agreement outlining joint valuesMOU 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)

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State funds – CT, DE, MAFederal funds (i.e., Title IV-E, IV-B) – IL and NHM lti l (i ti l t t f di

Funding

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Multiple sources (i.e., partial state funding, tobacco settlement, agency budget reallocation) – Sacramento, San Diego and Washington

Substance Abuse Specialists

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Substance Abuse Specialists

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Substance Abuse Specialists

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Program Context

Sacramento County population: 1.5 millionBetween Oct 2006 and Sept 2007, there were 1862 child abuse/neglect referrals accepted for investigation gAn estimated 70 to 80% of child welfare cases involve families affected by substance use

Sacramento County Prior to STARS and Dependency Drug Court

Reunification rate about 20-25%Parents unable to access substance abuse treatmentSocial workers, attorneys, courts oftenSocial workers, attorneys, courts often uninformed on parent progressDrug 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 fasterReunification is occurring fasterParents truly have “treatment on demand”All parties involved in the case are informed at every stage of treatmentAll parents receive random observed “instant” drug testing

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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.

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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.)

meetingsmeetings• 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

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Three Standard Court Orders

Treatment

Drug and Alcohol Testing Recovery 

Support

Specialists Contacts

Treatment Support Groups

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Primary purpose is to facilitate entry into treatment

Upon assessment help parent make phone 

call to treatment for 

Provide treatment documents such as 

brochure or program rules

TreatmentSubstance Abuse Specialist Roles

initial appt program rules

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If known, provide parent with treatment days and times 

– written (pocket 

calendar is best)

If needed provide number, 

documentation etc. of public transportation

Supply a map to treatment facility (best practice take them to facility the first time)

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Drug and Alcohol TestingSubstance Abuse Specialist Roles

From the start, set parent mindset regarding testing.  Tests are used to provide proof of 

compliance.  System l d k b t

Demonstrate how honesty about use helps case.  Social Worker and Court 

ti

Explain in detail the method of testing used.  Help the 

parent understand what exactly they 

b i bj t dalready knows about substance abuse 

problem

perception are being subjected to.

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Remember –

Always allow for honesty first!

Thoroughly explain consequences of deception – worse than positive test

Substance Abuse Specialist ContactsSubstance Abuse Specialist Roles

These serve as the

Should begin with intensity 

and frequency and taper 

down as case Utilize these Unlike other requirements

ll fas the foundation for the 

relationship between parent and specialist

down as case progresses (When possible, meetings 

should cater to parent needs –

treatment, home, work 

etc.)

contacts to collect 

paperwork and needed info – reduce 

impact

, allow for some 

deviation (only if 

testing would not have occurred)

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Attendance of Support GroupsSubstance Abuse Specialist Roles

Overcome resistance to attendance by fully 

Using meeting schedule, highlight 

Highlight meetings with 

Utilize buddy system –other 

parents or

Steer parents to beginner y y

explaining nature of meetings attending

g gmeetings close to 

home work etc.

childcare or any other 

special need

parents or alumni can attend 

meetings with parent

gmeetings and sober functions

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Explain to parent the need to attend these meetings – treatment is finite but meetings offer lifelong support

How Can You Make All Of This Work?

S i li t k ith li t th h t l th f

Location of specialist 

Specialists’ background and expertise

Cross training and training on how to use the specialist

Sustainable funding

Integrative practice

Buy‐in from different systems

Collaborative relationship and constant communication

Specialist works with client throughout length of case

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How Can You Make All Of This Work?

Location of specialist 

Specialists’ background and expertise

Sustainable funding

Buy‐in from different systems

Collaborative relationship and constant communication

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Sacramento County Recovery Specialists/Dependency Drug Court

Evaluation Data

85.3

80

100

ent

Treatment Outcomes: Admission Rates***(Ever been in AOD treatment)

53.2

0

20

40

60

Comparison With RS

Perce

***p<.001 Comp n=111; DDC n=2138 Source: CalOMS

Treatment Outcomes: Discharge Status

56.8

43.2

64.6

35.460

80

100

rcent

No significant difference

Source: CalOMSComp n=111; DDC n=2138

0

20

40

Satisfactory Unsatisfactory

Per

Comparison Court Ordered RS

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Treatment Discharge Status by Primary Drug Problem

***p<.001 Source: CalOMSComp n=111; DDC n=2138

Child Placement Outcomes at 36-months

46.160

80

100

nt

27.232.9

13.3

0.6

18.5

7.5

22.5

5.3 9.24.6

12.2

0

20

40

Reunification*** Adoption*** Guardianship*** FR Services*** Long‐Term Placement***

Other

Percen

Comparison Court‐Ordered

**p<.01; ***p<.001 Comp n=173; DDC n=1343 Source: CWS/CMS

Child Reunification Rates Over Time

Comp n=173; DDC 12 mos=2818; 24 mos= 2087; 36 mos=1343 Source: CWS/CMS

Child Adoption Rates Over Time

Comp n=173; DDC 12 mos=2818; 24 mos= 2087; 36 mos=1343 Source: CWS/CMS

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Long Term Child Placement Rates Over Time

Comp n=173; DDC 12 mos=2818; 24 mos= 2087; 36 mos=1343 Source: CWS/CMS

Child Reunification Rates by DDC Graduation Status Over Time

Comp n=173; DDC n=2138 Source: STARS; CWS/CMS

Adaptive Continuing Care

Mark D. GodleyChestnut Health Systems

Acknowledgements

This work was supported by:

• Westat Subcontract No. s8440,• SAMHSA Contract No.

HHSS28320070006I• NIDA Grant No: 5-R37-DA11323The 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.

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Presentation Aims

• What is adaptive continuing care• Key elements of adaptive continuing care• Describe two approaches to adaptive

continuing care• Results

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

Adaptive Continuing Care: Key Elements

• Monitor clients discharged from treatment for substance use disorders at planned intervalsintervals

• 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

Telephone-based Adaptive Continuing Care for Adolescents

Seattle, WA

Tucson, AZ

Bloomington, IL

Fitchburg, MA

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Adaptive Call Structure

• Weekly calls during the first 90 days after discharge from treatment, then monthlyy

• 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 p y g• 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

14:24

16:48

19:12

0:00

2:24

4:48

7:12

9:36

12:00

4/17

/201

0

5/1/

2010

5/15

/201

0

5/29

/201

0

6/12

/201

0

6/26

/201

0

7/10

/201

0

7/24

/201

0

8/7/

2010

8/21

/201

0

9/4/

2010

9/18

/201

0

10/2

/201

0

10/1

6/20

10

Percent of Adolescents Completing Planned Telephone Support Sessions

500

600

700

0

100

200

300

400

500

Bloomington Fitchburg Seattle Tucson

AttemptedCompleted

56%

67%

65% 57%

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Telephone Support Session Data (n=81)

70

80

90

100

0

10

20

30

40

50

60

% of Sessions endingwith goals

% of Sessions withgoals completed

Feb-April 2010May-July 2010

Outcome Measures

• Pre-post change scores in the following areas collected with the Global Appraisal of Individual Needs (GAIN):

– Prosocial Activities (including 12 step attendance)– Days of substance use in the community– Substance Problem Scale

Self-Help Activity Scale

2.5

3

3.5

0

0.5

1

1.5

2

2.5

Intake 3 Months

Outcomes of Adaptive Telephone Continuing Care

P ti i ti i

Pro-Recovery Activities

S b t USubstance-

R l t d

+.11

1%-.10

-.40 18%37%

Participation in Telephone Continuing

Care

Substance Use Frequency

Related Problems

-.11 +.56

Adaptive Telephone Continuing care was compared to a matched control group receiving standard referrals for continuing care only.

All coefficients >.10 are statistically significant

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Satisfaction with Telephone Support (n=25)

70%

80%

90%

100%

0%

10%

20%

30%

40%

50%

60%

sometimes-almostalways liked

receiving calls

always/almostalways thought

telephone supportworker was kindand encouraging

never/almost neverthought telephone

support worker wastoo demanding

thought calls werethe right amount of

frequency

thought telephonecalls were the right

length of time

would recommendcalls longer than thefirst 3 months post-

discharge

Early Re-Intervention (ERI) Experiment and Hypotheses

Monitoring and

Early Re-Intervention

Reduce Time to Re-admission

Less Successive Quarters

Using

Less Risk Behaviors, MH and Crime

Source: Dennis et al 2003, 2007; Scott et al 2005, in press

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

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 ret rning to treatmentconsider returning 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

mitt

ed 1

+ Ti

mes

50%

60%

70%

80%

90%

100%Time from relapse to

readmission reduce by 78% (45-13 = -32 months; d=-.41) 74% ERI-2 RMC*

(n=198)

48% ERI-2 OM( 195)

RMC increases the odds of re-entering treatment over 4 years by 3.1

Perc

ent R

eadm

Wilcoxon-Gehen statistic (df=1) = 28.60, p<.001

OR=3.1, p<.05

0%

10%

20%

30%

40%

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45

Months from 1st Follow-up In Need for Treatment,

(n=195)

Source: Scott & Dennis (2009); Dennis & Scott (in press)

The size of the effect grew every quarter

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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 activitieshelp 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

Source: Scott & Dennis (2009); Dennis & Scott (in press)

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?g– 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, well-

supervised volunteers

Questions and DiscussionQuestions and Discussion

Register Now

http://www.cffutures.org/conference2011Gaylord National Resort and Convention Center on the Potomac—National Harbor, MD

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Contact Information

Mark D. Godley, Ph.D.Chestnut Health Systems

448 Wylie Dr.

Sandy RobinsonChildren and Family Futures4940 Irvine Blvd, Suite 202

Normal, IL 61761

Email: mgodley@chestnut.org

Irvine, CA 92620

Email: sanfordbest@sbcglobal.net