Child and Family Team Practice for Arizona Children Under Court Jurisdiction

Frank Rider, Clinical Practice Improvement

Arizona Division of Behavioral Health Services

June 16, 2006

Regional Contractors- 2006

Region Served RBHA/TRBHA

Apache, Coconino, Mohave, Navajo and Yavapai Counties

Northern Arizona Regional Behavioral Health Authority

Gila, Pinal, LaPaz and Yuma Counties Cenpatico Behavioral Health of Arizona

Cochise, Graham, Greenlee, Pima and Santa Cruz Counties

Community Partnership of

Southern Arizona (CPSA)

Maricopa County ValueOptions

Gila River Indian Community

Pascua Yaqui Tribe

Tribal RBHAs

J.K. Settlement Agreement

Requires ADHS and AHCCCS to: Improve frontline practice (CFT, best practices) Enhance capacity to deliver needed services

Promote collaboration among public agencies and

stakeholder participation

Develop quality management/improvement system: Structure Process Outcomes

Covered BH Services

Support Services Behavioral Health Day Programs Prevention Services Rehabilitation Services Medical Services Treatment Services Crisis Intervention Services Inpatient Services Residential Services

Interagency Memorandum of Understanding

While ADHS and AHCCCS were named as defendants in the J.K. lawsuit, Arizona’s remaining child-serving agencies

DES, ADJC, AOC and ADE have signed a Memorandum of Understanding,

voluntarily and collectively embracing the Arizona Vision and the 12 Arizona Principles.

(April 2002)

Child and Family Team Process

Services planning is family-centered, strength-based, individually tailored, culturally informed, and collaborative across systems

Families report feeling hopeful, more willing to positively engage their own strengths as respected member of team

Service plans identify and promote reliance on informal and natural supports in combination with formal services

“Wraparound” Works

“Building on family strengths is essential if we are to prevent and control juvenile delinquency behavior. The process that embraces this concept is more formally known as Wraparound. This process can help prevent families from becoming abuse, neglect and delinquency statistics. It works well as an intervention model even for the most severe cases of abuse, neglect or delinquency.”

Hon. David C. Bonfiglio, Superior Court Judge, 6/01 Testimony before Indiana Select Legislative Committee on Education

Structural Accomplishment in Arizona

On January 29, 2003, Gov. Janet Napolitano ordered the expansion of the 300 Kids Pilot to statewide implementation

1/31/2005: 13.5% of 34,000 with CFTs 5/31/2006: 32% with CFTs

Children involved with CPS & Juvenile Justice are priority populations

Structural Accomplishment in Arizona

7/1/04 – CMDP Capitation ($12- to 25-million) in new service capacity

Therapeutic Foster Care: 9/03 – 9 placements statewide 5/06 – 354 placements statewide

The Arizona Vision - Qualities

“Services will be tailored to the child and family and provided in the most appropriate setting, in a timely fashion, and in accordance with best practices, while respecting the child’s and family’s cultural heritage.”

CFT Process – Qualitative Status

Arizona CFT Model is Sound: National Wraparound Initiative Cited by National Research and training Center (2005)

CFT Facilitator Competency Measurement (10/05) CFT Process Measurement

Hundreds of Practice Reviews/(family) interviews on Sample of CFTs Quarterly (since 10/05)

Promising evidence of improvement in Maricopa Co. Strengthening statewide practice improvement process

(10/06)

The Arizona Vision - Outcomes

In collaboration with the child and family and others, Arizona will provide accessible behavioral health services designed to aid children to: achieve success in school live with their families avoid delinquency become stable and productive adults

“Wraparound” Works

Example – Wraparound Milwaukee: Residential placements decreased by 60% Psychiatric hospitalization decreased by 80% Reduced recidivism by delinquent youth Overall cost of care per child decreased

(Bruce Kamradt, Child Welfare League of America, 2001 Natl Conference)

Wraparound approach addresses recovery environment, essential to positive, sustained outcomes in treating adolescent substance use disorders

(Michael Dennis PhD, Chestnut Health Systems-November 2005)

Promising Data on 30,000 Arizona Children (3/31/05)

Success in School – Past Six Months: Age 5-11: 12.8% higher with CFT (77.9%) Age 12-17: 15.5% higher with CFT (65.1%)

Lives with Family – Past Six Months: Age 5-11: 8.5% higher with CFT (88.8%) Age 12-17: 7.0% higher with CFT (75.8%)

Promising Data on 30,000 Arizona Children (3/31/05)

Avoids Delinquency – Past Six Months Age 5-11: 12.8% higher with CFT (77.9%) Age 12-17: 15.5% higher with CFT (70.9%)

Preparation for Adulthood – Past Six Months Age 5-11: 10.6% higher with CFT (62.9%) Age 12-17: 15.3% higher with CFT (58.7%)

Promising Data on 30,000 Arizona Children (3/31/05)

(Increased) Stability – Past Six Months Ages 5-11: 15.1% higher with CFT (74.6%) Ages 12-17: 19.8% higher with CFT (71.1%)

(Increased) Safety – Past Six Months Ages 5-11: 13.7% higher with CFT (69.2%)

Ages 12-17: 16.0% higher with CFT (67.3%)

Implications for Legal Process

Use Child and Family Teams to develop and present to the Court “options” leading to a single, unified plan across multiple agencies, intended to respect the mandates of each involved system.

Creative, individualized plans will be based on “discovered” strengths and needs of each child and family, reflecting not only the input of professionals, but of the families and youth themselves.

Advocate that the Court offer flexibility for a child and family team to develop a timely plan to meet defined requirements for safety and well-being. Use this as an alternative to ordering specific placements and treatments for children.

Residential Treatment Is Ineffective

64-86% SA youth relapsed within one year of RTC discharge

6 states,7 year follow up: 75% of youth treated at an RTC: 45% readmitted to a BH facility

30% incarcerated in a correctional facility (Greenbaum, 1998)

8% children served in RTCs costing 25% of national children’s BH budgets

From: U.S. Surgeon General’s Report on Mental Health, 1999

Why Residential Treatment Is Ineffective

Disrupted attachments/trauma due to prolonged separation from family

Fewer interpersonal experiences that support their well-being

Limited individual academic development due to high levels of structure

Limited involvement in positive aspects of school (extra-curricular)

Learned antisocial/bizarre behavior - exposure to other disturbed children

Limited “real life” opportunities to learn skills for independent living

Higher re-entry rates after reunification vs. youth in family-centered care

Barth, “Institutions vs. Foster Homes: The Empirical Base for a Century of Action” (Jordan Institute for Families, June 2002)

What Is Effective?

Therapeutic Foster Care (TFC) - as effective as RTC at ½ the cost; reduced violent crimes by 70% among 12-18 yr. old youth

Well structured outpatient programs with highly targeted, intensive interventions - Multi-systemic Therapy (MST) better than hospitalization for juvenile justice youth

Maintaining strong ties to the community in real world settings

Community/home based interventions that target change in peer associations

Case managers with smaller caseloads using a “wraparound” model of care

From: U.S. Surgeon General’s Report (1999)

Arizona’s Best Practices

No evidentiary base to support effectiveness of residential treatment.

Conclusive evidentiary base to support effectiveness of:

Wraparound/Child and Family Teams Therapeutic Foster Care

Friedman (Katie A. Declaration, 10/05)

Thank You – Questions?

Conditions When Needed Residential Treatment Can Succeed:

Parent (or other permanent adult) connection from beginningUse of family group conferencesFit services to child/family’s strengths, needs and permanency planEntrances/exits are part of a phased case planCPS prioritizes family visits/extended family contactActive involvement in residential program by parent/adult connectionPermeable boundaries between the institution and the communityFamilies/older youth play a leading role in discharge planning~transitionStaff involvement for up to a year following youth exiting careResidential programs send youth into community as volunteers

Shay Bilchik, President/CEO,Child Welfare League of America (3/05)