1. 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

2. Regional Contractors- 2006 Region ServedRBHA/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

3. 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

4. Covered BH Services  Support Services  Behavioral Health Day Programs  Prevention Services  Rehabilitation Services  Medical Services  Treatment Services  Crisis Intervention Services  Inpatient Services  Residential Services

5. 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)

6. 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

7. “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

8. 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

9. 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

10. 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.”

11. 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)

12. 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

13. “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)

14. 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%)

15. 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%)

16. 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%)

17. 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.

18. 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

19. 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)

20. 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)

21. 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)

22. Thank You – Questions?

23. Conditions When Needed Residential Treatment Can Succeed:  Parent (or other permanent adult) connection from beginning  Use of family group conferences  Fit services to child/family’s strengths, needs and permanency plan  Entrances/exits are part of a phased case plan  CPS prioritizes family visits/extended family contact  Active involvement in residential program by parent/adult connection  Permeable boundaries between the institution and the community  Families/older youth play a leading role in discharge planning~transition  Staff involvement for up to a year following youth exiting care  Residential programs send youth into community as volunteers Shay Bilchik, President/CEO,Child Welfare League of America (3/05)