Evaluation of Arizona Families F.I.R.S.T. Annual Evaluation Report Submitted on: December 4, 2002 Submitted to: Arizona Department of Economic Security Division of Children, Youth and Families Phoenix, Arizona Contract #: E4371670 Submitted by: James Bell Associates 1001 19th Street, North., Suite 1500 Arlington, VA 22209 (703) 528-3230 FAX (703) 243-3017 in collaboration with: Westat, Inc., Rockville, MD and Professional Consultation Consortium, Phoenix, AZ TABLE OF CONTENTS Page Executive Summary ...................................................................................................................................... i Chapter I. Introduction ......................................................................................................................... A. Background Information on the Arizona Families F.I.R.S.T. Program ........................... B. Data Sources Analyzed for the Annual Report............................................................... C. Organization and Contents of Annual Report................................................................. 1 1 2 3 Chapter II. Overview of Evaluation Framework .................................................................................. 5 Chapter III. Description of Arizona Families F.I.R.S.T. Clients and Services Received................... A. Characteristics of Individuals Referred........................................................................... B. Characteristics of AFF Participating Clients ................................................................... 1. Demographic Characteristics ................................................................................... 2. Family Size and Marital Status................................................................................. 3. Education Level and Employment............................................................................ 4. Title XIX Participants................................................................................................ 5. Substance Abuse ..................................................................................................... C. Service Activity ............................................................................................................... 1. Referrals................................................................................................................... 2. Assessments ............................................................................................................ 3. Levels of Client Engagement in Treatment.............................................................. 4. Substance Abuse Treatment Services..................................................................... 5. Time Spent in Treatment.......................................................................................... 8 8 9 10 12 13 15 16 19 19 21 23 25 30 Chapter IV. Perceptions of Timeliness, Availability, and Accessibility of Services......................... A. Timeliness of Services to Clients.................................................................................... 1. Assessments ............................................................................................................ 2. Service Plans ........................................................................................................... 3. Engagement in Treatment........................................................................................ 4. General Factors Perceived to Affect Timeframes .................................................... 5. Perceived Changes in Timeframes and Contributing Factors ................................. B. Perceived Availability of Services................................................................................... 1. Differences Between Rural and Urban AFF Provider Agencies .............................. 2. Program Capacity..................................................................................................... 3. Use of Different Terminology That May Affect Perceived Availability...................... 4. Perceived Changes in Availability and Contributing Factors ................................... C. Perceived Changes in the Accessibility of Services ....................................................... 1. Transportation Issues............................................................................................... 2. Hours of Operation ................................................................................................... 3. Clients’ Priority to Access Services.......................................................................... 4. Changes in Accessibility to Services and Contributing Factors............................... 33 34 35 36 36 37 38 38 39 39 40 40 42 42 43 43 43 D. Implementation of Arizona Families F.I.R.S.T. Collaborative Partnerships ................... 1. Collaborative Partners: A Description ...................................................................... 2. The Role of Subcontractors ..................................................................................... 3. Successes in Collaboration...................................................................................... 43 44 48 48 Chapter V. Client Satisfaction ............................................................................................................... A. Clients’ Participation in Services and Activities .............................................................. B. Clients’ Experiences and Satisfaction with AFF ............................................................. C. Clients’ Need for Services .............................................................................................. D. Experiences With Residential Treatment ....................................................................... E. Clients’ Knowledge and Understanding of the AFF Program......................................... 49 50 50 51 51 52 Chapter VI. Policy Activities and Systems Level Changes................................................................. A. Quality Improvement Site Visits...................................................................................... B. Development of Joint Protocols...................................................................................... C. ADHS Staff Liaison for AFF ............................................................................................ D. Coordination Meetings.................................................................................................... E. Sharing of Resources ..................................................................................................... 53 53 53 54 55 55 Chapter VII. Summary and Conclusions................................................................................................ 57 Appendix A: Appendix B: Appendix C: Appendix D: Mapping of DHS Codes to AFF Services .......................................................................... AFF Project Director Interview........................................................................................... Site Level Description of AFF Collaborative Partnerships ............................................. Lessons Learned in the Implementation of Arizona Families F.I.R.S.T......................... 61 69 75 89 EXECUTIVE SUMMARY Arizona Families F.I.R.S.T. and Its Development in Brief Arizona Families F.I.R.S.T. (AFF) was established by Arizona Revised Statute (ARS) 8-881 (Senate Bill 1280, passed in the 2000 legislative session) and is administered jointly by the Arizona Department of Economic Security (ADES) and the Arizona Department of Health Services (ADHS), with ADES designated as the lead agency. The legislation established a statewide program for substance abusing families entering the child welfare system as well as those families receiving cash assistance through Temporary Assistance for Needy Families (TANF). The legislation recognized that substance abuse is a major problem contributing to child abuse and neglect, and is also a significant barrier for those attempting to re-enter the job market or maintain employment. In the Spring of 2001, nine AFF providers received contracts through ADES to implement a community substance abuse prevention and treatment program under Arizona Families F.I.R.S.T. Contract providers across the State of Arizona were funded so that all counties would be covered by AFF services. The agencies funded included: TERROS; Southeastern Arizona Behavioral Health Services (SEABHS); Community Partnership of Southern Arizona (CPSA); Arizona Partnership for Children (AZPAC) in Coconino, Yavapai, and Yuma counties; Horizon Human Services; WestCare Arizona; and Old Concho Community Assistance Center. Over the first year of the program, AFF provider agencies worked to: develop a referral process; screen, assess, and treat clients within the required AFF timeframes; develop collaborative partnerships with subcontractors and other community agencies; and coordinate treatment services with RBHA providers when the AFF client was in the Title XIX program. By March 31, 2002, 1,447 individuals had been referred to the AFF program (84% referred from CPS) and 803 individuals had participated in treatment services. The evaluation of AFF, required by ARS 8-881, focuses on the implementation of the AFF community substance abuse prevention and treatment programs at all nine sites, the factors that contribute to their success, and the extent to which the legislature’s outcome goals of increases in timeliness, availability and accessibility of services; recovery from alcohol and drug problems; child safety; permanency for children through reunification; and the achievement of self-sufficiency through employment can be obtained. The focus during the first year of the evaluation was on establishing a cross-agency, client-level data base system, documenting the implementation of AFF through quarterly data collection at each of the AFF sites, and analyzing data on clients’ utilization of services. Overview of Annual Evaluation Report This report presents service utilization data through March 2002 and process data collected through June 2002.1 The evaluation data have contributed to a better understanding of the characteristics of AFF participating clients; the types of drugs used by clients across the nine AFF sites, including polydrug use patterns; referral trends during the first year and site-level factors influencing referral patterns; levels of client engagement in services and service utilization patterns; and lengths of stay in treatment. Process data presented in this report offer an early indication of changes in the timeliness, availability, and accessibility of treatment services as perceived by AFF program directors. Data collected through interviews with AFF program directors at each of the AFF sites indicate that several AFF provider agencies have made significant progress in establishing a collaborative group to help support the goals of AFF and provide services to clients while some AFF providers still have more work to do 1 The evaluation plan does not call for reporting on outcomes until the second year of the program. i Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Executive Summary in that area.2 The majority of AFF project directors perceive that the ARS 8-881 funding has had an impact on increasing the availability of treatment and support services. Although treatment recovery data are not yet available, the findings that AFF clients are engaged in services at a high rate and are spending several months in treatment services are positive results. Key findings of this annual report are summarized below, under the research questions that were examined in this report. What Are the Characteristics of Participating Clients? • Overall, 58 percent of participating clients were in the Title XIX program (i.e., enrolled in Medicaid); 34 percent were non-Title XIX. • Seventy five percent of participating clients were female, and 25 percent were male. Twenty two percent were between 18 and 25 years old; 37 percent were between 26 and 33 years; 31 percent were from 34 to 41 years of age; and 10 percent were 42 years and older. • Overall, 62 percent of participants were White, 14 percent were Black, 18 percent were Hispanic, and 6 percent were Native American/Alaskan Native. There was both within-site and cross-site variation with respect to race. Overall, the racial distribution of clients engaged in the program was similar to the racial distribution of clients referred. • Participating families varied with respect to family size and the number of children in their families. Twenty seven percent of families had only one child; 27 percent had two children; 20 percent had three children; 10 percent had four children; and 16 percent had five or more children. • Approximately 44 percent of participating clients across the AFF sites did not complete high school. This pattern was consistent across sites—for clients served by both urban and rural provider agencies. What Do We Know About Drug Use Among AFF Clients? • With respect to drug use reported at the time of enrollment in AFF, 62 percent of participating clients reported using alcohol; 49 percent used marijuana; 37 percent said they used cocaine; 42 percent used methamphetamines; six percent used heroin/morphine; and eight percent used other hallucinogens. There was site variation in drug usage: Use of cocaine was highest at CPSA (65% of clients); the heroin/morphine; and eight percent used other hallucinogens. There was site variation in drug usage: Use of cocaine was highest at CPSA (65% of clients); the highest rates of marijuana use were reported by CPSA (74%), AZPAC Yavapai (73%), and SEABHS (60%). The rate of methamphetamine use was over 50 percent at AZPAC Yavapai (79%), AZPAC Yuma (82%), Horizon (56%), and WestCare (71%). • The polydrug co-morbidity patterns among participating clients indicated that for the 26 percent of participants who reported that methamphetamine was their most frequently used substance, 50 percent also used alcohol, and 47 percent also used marijuana. Twenty percent of participants reported that their most frequently used drug was cocaine. Among this group, 70 percent also used alcohol and 63 percent also used marijuana. 2 In-depth interviews also were conducted on a quarterly basis with different informants interviewed each quarter, including treatment providers, referral agency staff, collaborative partners, and representatives of RBHAs. The implementation findings have been summarized throughout this report and are available in more detail in the Quarterly Evaluation Reports. ii Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Executive Summary To What Extent are AFF Clients Engaged in Substance Abuse Treatment? • Engagement in treatment services was one of the Steering Committee’s3 suggested performance measures. Fifty five percent of all clients referred to AFF are subsequently engaged in treatment services.4 Engagement in treatment can be viewed as an intermediary outcome that is attained prior to observing long-term outcomes related to recovery. • Overall, clients who receive an assessment are likely to have a service plan developed and enter treatment. Seven of the nine AFF provider agencies completed assessments on 70 percent or more of their referred clients, and overall, 80 percent of assessed clients had a service plan developed. • At six of the nine AFF sites, there was a consistent pattern whereby 100 percent of clients with a service plan went on to receive treatment services. At all AFF sites, 91 percent or more of those with a service plan received treatment services. To What Extent are AFF Clients Staying in Treatment Services? • With respect to length of stay in treatment, 51 percent of clients who entered the program by September 30, 2001 remained in treatment for three months or longer, and 37 percent stayed in treatment for at least four to six months. • Among clients who entered the program by April 1, 2001, over 55 percent stayed in treatment for six months or longer, 18 percent stayed in treatment for eight to ten months, and 20 percent remained in treatment for 10 months or longer. These utilization patterns are promising given that research on substance abuse treatment emphasizes that the longer a client stays in treatment, the more likely it is that the treatment will result in long-term behavior change.5 To What Extent Has AFF Increased the Timeliness, Availability, and Accessibility of Treatment Services? • Seven of the AFF provider agencies reported a perceived increase in the timeliness of service delivery since they began implementation of AFF more than a year earlier. Factors to which they attributed these increases included AFF policies and requirements regarding the timeframes within which clients must be screened, assessed, and have service plans developed; ADES monitoring practices through quality improvement visits and corrective action plan letters; and AFF provider agencies’ accountability to ADES when they fail to meet timeframe requirements. • The outreach and engagement component of AFF allows AFF provider agencies to spend time and resources on engaging clients in the screening and assessment process (i.e., there are AFF dollars available for outreach and engagement activities). The outreach and engagement component was perceived by AFF provider agencies to contribute toward an increase in the timeliness of serving clients. • AFF collaborative partnerships have increased the awareness of services available among the referral agency staff, which in turn has shortened the timeframes within which referrals are made 3 The AFF Steering Committee was formed as a policy committee to provide guidance and oversight to AFF and initially took on the role of specifying policies and requirements to help shape the direction of the program and reviewing implementation procedures. 4 This level of engagement is higher than the engagement rate for another child welfare-substance abuse partnership program run through the Connecticut Department of Children and Families – Project Safe, where only 37 percent of caregivers referred by the child welfare agency for assessment and treatment actually engaged in treatment (www.maine@aan.usm.maine.edu/nosafe/sheehan.html; accessed 10/25/02). 5 Hubbard, R., Marsden, M., Rachal, J., Harwood, H., Cavanaugh, E., & Ginzburg, H. (1989). Drug Abuse Treatment: A National Study of Treatment Effectiveness. Chapel Hill: The University of North Carolina Press. iii Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Executive Summary because referral staff know what services are available to clients who need help and they know the process for making referrals. • Seven AFF provider agencies reported a perceived increase in the availability of treatment services over the past year. This increase was attributed to the following factors: AFF funding through ARS 8-881 to provide treatment services for non-Title XIX clients, which has increased the number of treatment slots available in Arizona for this population; and AFF funding for support services, which has increased the supply of services such as child care, housing assistance, and transportation for both Title XIX and non-Title XIX clients. • All nine AFF provider agencies reported a perceived increase in the accessibility of treatment services. This increase was attributed to a number of factors. First, the AFF requirement that there be a coordinated, comprehensive service delivery system that includes referral agencies (CPS and Jobs) and the local RBHA has helped to increase clients’ access to services provided through multiple agencies and treatment providers in their local communities. Second, the familycentered treatment model implemented under AFF includes the provision of individualized support services to clients (i.e., tailored to the particular needs of the client and his/her family), such as child care and transportation, which has increased clients’ ability to gain access to core treatment services. Third, AFF provider agencies indicated that increased communication has resulted from their collaborative partnerships, which has contributed to an increase in the number of crossagency referrals and clients’ access to different services offered through various agencies that network with the AFF provider agency. • Another important factor contributing to improvements in availability and accessibility is the larger context in which AFF was implemented during 2001. Proposition 204 had passed, allowing for an expansion of Title XIX eligibility as well as covered services under Medicaid beginning in October 2001. The higher volume in Medicaid clients has, in turn, enabled the Title XIX provider network to expand its services and build greater capacity. What Do We Know About Clients’ Satisfaction with AFF? • Clients reported that their relationships with AFF case managers, treatment staff, and counselors were extremely beneficial to them and that they had frequent contact with these professionals. Treatment staff who were recovered addicts were especially helpful to them because these staff were knowledgeable about the recovery process from personal experience. • Clients indicated that their substance abuse treatment therapists communicated with their CPS or Jobs case managers regarding their case plan, treatment plan, and the progress that clients were making. Clients reported that they found this information sharing to be helpful, for example, when treatment providers were able to keep their CPS case manager informed about their progress in an effort to help them regain custody of their children. To What Extent Has There Been Increased Coordination Across Systems? • Increased coordination between the treatment system and the child welfare system was reported after the first year of implementation. AFF provider agencies described how AFF has removed the barriers to getting CPS clients into treatment. Where previously, CPS staff provided primary caregivers with a referral for treatment but left the responsibility to the primary caregiver to follow through, increased coordination has resulted in treatment staff seeking out the clients to complete a screening and assessment and using motivational techniques to get them into treatment. • Coordination between treatment providers and other community agencies has increased, largely through improved communication. CPS staff have become involved in treatment planning and case staffings, and treatment providers share information with CPS staff on the progress that clients are making in their treatment. In addition, some AFF provider agencies that are not Title iv Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Executive Summary XIX providers (AZPAC Coconino and AZPAC Yavapai) report that their RBHAs are involved in a high level of case coordination and treatment planning and have instituted new practices to coordinate the services provided to AFF clients. • Increased coordination at the State level, between ADES and ADHS, has occurred during the first year of the AFF program. Factors that have contributed to this coordination include: regular communication and meetings between the AFF administrator at ADES and the Bureau Chief of Substance Abuse Prevention and Treatment at ADHS; an AFF liaison from ADHS who spends time onsite at the ADES office, participates in trainings for AFF provider agencies and RBHAs, and participates in AFF quality improvement site visits; the development of joint protocols between the two agencies that have been implemented and followed by agency staff; and even the sharing of resources between agencies. What Other Lessons Have Been Learned After the First Year of the Program? • AFF program directors acknowledged the importance of collaborating with providers and other agencies in their local communities to enhance the services provided for clients, and they believed that continued efforts to increase collaboration was an important activity in the ongoing implementation of AFF. • Factors cited by AFF program directors that were important facilitators to implementation of AFF treatment services were AFF’s family-centered treatment philosophy, which allowed providers to address issues in the family as part of a client’s treatment program; the emphasis on comprehensive and coordinated services; the adherence of AFF to “best practices” standards set forth in the substance abuse literature; perceived support from ADES administrators and staff; and the ADES program monitoring and accountability that is in place. • Barriers noted by AFF program directors regarding implementation of AFF services included: receiving a lower number of referrals than expected; not having separate funding to carry out case management activities; in some communities, having a lack of agencies to offer aftercare and supports for clients; and dealing with agencies who had their own perspectives regarding best practices for substance abuse treatment (e.g., the perception that residential treatment is the only option for clients with substance abuse problems). AFF program directors across sites also discussed the lack of available residential treatment services as a barrier to meeting clients’ treatment needs. Conclusion Overall, information presented in this annual report indicates that during the first year of the program, AFF provider agencies have been successful in implementing the AFF program requirements. The referral, outreach, screening, and assessment practices are in place and clients with service plans developed are entering treatment services and are remaining in treatment for several months. These findings with respect to engagement in treatment and retention in treatment can be viewed as intermediate outcomes that are expected on the pathway to ultimately achieving expected outcomes concerning recovery, permanency, and employment. The emerging findings reported through yearend process data collected across the nine AFF provider agencies indicate that provider agencies already perceive improvements in timeliness, availability and accessibility of services. Other systems-level outcomes, such as increased service coordination and coordination at the State level also have been identified. While outcomes related to recovery, child welfare, and employment will not be reported until next year, the preliminary findings are positive with regard to improved coordination of services, increased availability, and access to services, and relatively high rates of client engagement and retention in services. v CHAPTER I INTRODUCTION Arizona Families F.I.R.S.T. (Families in Recovery Succeeding Together) was established as a community substance abuse prevention and treatment program by ARS 8-881 (Senate Bill 1280, which passed in 2000 legislative session). Under the requirements of the Joint Substance Abuse Treatment fund that was established under the legislation, Section 8-884 requires an evaluation of the Arizona Families F.I.R.S.T. program (AFF). The evaluation of AFF focuses on the implementation of community substance abuse prevention and treatment programs at each of the nine AFF sites across the State of Arizona, the factors that contribute to their success, and the extent to which outcome goals can be attained such as increases in timeliness, availability and accessibility of services; recovery from alcohol and drug problems, child safety, permanency for children through reunification, and the achievement of self-sufficiency through employment. The focus during the first year of the evaluation was on establishing a cross-agency, client-level data base system, documenting the implementation of AFF through quarterly data collection at each of the AFF sites, and analyzing data on clients’ utilization of services. A. Background Information on the Arizona Families F.I.R.S.T. Program Arizona Families F.I.R.S.T. is administered jointly by the Arizona Department of Economic Security (ADES) and the Arizona Department of Health Services (ADHS), with ADES designated as the lead agency. The legislation established a statewide program for substance abusing families entering the child welfare system as well as those families receiving cash assistance through Temporary Assistance for Needy Families (TANF). The legislation recognized that substance abuse in families is a major problem contributing to child abuse and neglect, and that substance abuse can present significant barriers for those attempting to re-enter the job market or maintain employment. Federal priorities under the Adoption and Safe Families Act (ASFA) that address child welfare outcomes, such as permanency and shorter time frames for reunification, coupled with the time limits established under the TANF block grant, also were factors behind the legislation. The purpose of AFF is to develop community partnerships and programs for families whose substance abuse is a barrier to maintaining, preserving, or reunifying the family, or is a barrier to maintaining self-sufficiency in the workplace. The Joint Substance Abuse Treatment Fund was established to coordinate efforts in providing a continuum of services that are family-centered, child focused, comprehensive, coordinated, flexible, community based, accessible, and culturally responsive. These services were to be developed through government and community partnerships with service providers (including subcontractors and Regional Behavioral Health Authorities—RBHAs), as well as through partnerships with other agencies such as faith-based organizations, domestic violence agencies, and social service organizations. The Legislature defined in ARS 8-884 the following outcome goals to be evaluated: • Increase the availability, timeliness, and accessibility of substance abuse treatment to improve child safety, family stability and permanency for children in foster care or other out-of-home placement, with a preference for re-unification with the child’s birth family. • Increase the availability, timeliness, and accessibility of substance abuse treatment to achieve self-sufficiency through employment. • Increase the availability, timeliness, and accessibility of substance abuse treatment to promote recovery from alcohol and drug problems. 1 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Introduction The AFF Steering Committee further required that the following performance measures be used to evaluate the effectiveness of the program: • Reduction in the recurrence of child abuse and/or neglect. • Increase in the number of families either obtaining or maintaining employment. • Decrease in the frequency of alcohol and/or drug use. • Decrease in the number of days in foster care per child. • Increase in the number of children in out-of-home care who achieve permanency. In the Spring of 2001, nine provider agencies received contracts through ADES to implement a community substance abuse prevention and treatment program under Arizona Families F.I.R.S.T. Contract providers across the State of Arizona were funded so that all counties would be covered by AFF services. The agencies funded included: TERROS; Southeastern Arizona Behavioral Health Services (SEABHS); Community Partnership of Southern Arizona (CPSA); Arizona Partnership for Children (AZPAC) in Coconino, Yavapai, and Yuma counties; Horizon Human Services; WestCare Arizona; and Old Concho Community Assistance Center. The AFF provider agencies and the geographic areas they serve are summarized in Exhibit I-1. Exhibit I-1 AFF Provider Agencies and Counties Served AFF Provider Agency County TERROS Maricopa Community Partnership of Southern Pima Arizona (CPSA) Arizona Partnership for Children (AZPAC) Coconino Old Concho Community Assistance Center Apache/Navajo AZPAC Yavapai AZPAC Yuma WestCare Arizona La Paz/Mohave Horizon Human Services Pinal/Gila Southeastern Arizona Behavioral Health Cochise, Graham, Services (SEABHS) Greenlee, Santa Cruz Among the nine AFF provider agencies, five are not Title XIX providers (AZPAC Coconino, AZPAC Yavapai, AZPAC Yuma, WestCare, and Old Concho) and must refer Title XIX AFF clients to a Title XIX provider/RBHA for their treatment services. The other AFF provider agencies are Title XIX providers (TERROS, CPSA, SEABHS, and Horizon) and provide treatment services for both Title XIX and non-Title XIX AFF clients. In February 2002, ADES renewed all nine AFF provider agencies’ contracts through June 30, 2003. Provider rates were increased approximately five percent for referrals and assessments, and some provider agencies received individual rate increases for specific services. B. Data Sources Analyzed for the Annual Report This annual report draws upon data from multiple sources. Service utilization data cover the period from March 2001 through March 31, 2002, which is the first full year of the program’s operation. Service utilization data were obtained from each of the AFF provider agencies and electronically transmitted into the client-level database maintained by the evaluator. In addition, service data were obtained through ADHS for this same time period (for services utilized by Title XIX AFF clients) from the CEDARS and ENCOUNTER data systems. Data on client characteristics were supplied by AFF provider agencies using information available from the assessments completed with clients. 2 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Introduction During the course of the first year, quarterly site visits were conducted to each of the AFF provider agencies to assess different areas of program implementation (e.g., referral process; determining levels of care; coordinating treatment services). Quarterly evaluation reports were prepared to summarize the findings with respect to implementation. Where implementation data from the quarterly reports are useful for interpreting quantitative findings that are reported, we have incorporated findings from the quarterly process data in this report. To assess perceptions of changes in timeliness, availability, and accessibility of services after the first year of the program, in-depth interviews were conducted with AFF program directors and agency administrators during June and July 2002. The qualitative findings from these interviews were analyzed and are reported in Chapter IV. Data on collaborative partnerships were obtained through the year-end AFF program manager interviews and through an analysis of collaboration matrices completed by each AFF program director. Service coordination was assessed through the program director interviews conducted at the end of the first year and through process data collected during the quarterly site visits (e.g., interviews with referring agency staff and RBHA staff). State-level coordination was examined through interviews conducted with ADES and ADHS administrators and staff at the end of the first year, and through a review of policy documents made available by the program administrator. AFF client satisfaction was assessed through focus groups and interviews conducted during site visits in February and March 2002. Focus groups were conducted with clients from TERROS, AZPAC Yuma, Horizon, and Old Concho. At the remainder of AFF sites, face-to-face individual interviews or telephone interviews were conducted with clients. The criteria for inclusion in the focus groups and interviews was that clients needed to be currently enrolled in AFF and they needed to be receiving some type of substance abuse treatment service. More detail regarding the specific methodologies used has been included in Chapters III, IV, and V where the findings of our analyses are presented. C. Organization and Contents of Annual Report This report begins with a brief overview of the evaluation framework that was used to guide the evaluation of AFF (Chapter II). In Chapter III, findings with respect to characteristics of referred and participating AFF clients are presented. This chapter also reports on service activity for participating clients during the first year of the program, including levels of engagement, treatment services utilized, and lengths of stay in treatment. Data in Chapter III, in general, are presented at the AFF provider agency level as well as cross-site (i.e., statewide totals). Process data collected during the year during site visits have been reported previously in Quarterly Evaluation Reports that addressed program implementation. Some of these data have also been incorporated into Chapter III to help interpret some of the patterns of service utilization at the site level. Also, some of the State-level policies that impacted the program, overall, have been included in this chapter, as appropriate. Chapter IV presents preliminary findings with respect to perceived changes in timeliness, availability, and accessibility of services. These were some of the legislative outcome goals and had been included in the evaluation plan. This annual report is the first time that data have been reported through a systematic qualitative analysis to address preliminary changes in these areas (as perceived by AFF program directors). The chapter also includes a discussion of the implementation of collaborative partnerships based on qualitative interview data as well as an analysis of collaborative partner matrices that each program director completed. 3 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Introduction Chapter V presents findings on client satisfaction based on interviews and focus groups with clients at each of the nine AFF provider sites, and Chapter VI summarizes policy activities undertaken at the State level that have resulted in increased coordination across state agencies during the first year of the program. Finally, Chapter VII provides a summary and conclusion of the major findings presented in the annual evaluation report. 4 CHAPTER II OVERVIEW OF EVALUATION FRAMEWORK The evaluation design that was developed for AFF includes both a process study and an outcome study. The process study focuses on program implementation to determine whether AFF provider agencies implemented the service model as intended by the legislation and program administrators. The process study also is useful for explaining why outcomes were achieved or not achieved. The outcome study addresses whether the AFF outcome goals and performance measures were achieved. As well, other outcomes in the areas of recovery, family stability, safety, permanency, selfsufficiency, and systems change are addressed. The outcome study addresses outcome findings at both the participant and systems levels. The evaluation framework upon which the AFF evaluation is based includes a number of models to be used in understanding the program from multiple levels—from the conceptualization of the program by policymakers to the actual experience of clients who enter the program and utilize the substance abuse treatment services. These models include: • The Policy Model: This model provides the standard description of the design of the program against which subsequent implementation of AFF is analyzed. Data to address the policy model are gathered from document reviews and interviews with policymakers. This model reflects the way in which the state administrators, legislators, and various stakeholders envisioned the program and how it was designed to operate. In the First Annual Evaluation Report on AFF (October 2001), an analysis of program policies, policy-level documents, the RFP, the Vision Statement, the role of the Steering Committee, and activities of ADES to help implement the program was conducted and findings were presented. In the current annual report, policy issues and changes have been included in various chapters to help interpret program models or what is occurring at the operational level. As well, a more detailed discussion of policy-level changes during the first year is provided at the end of Chapter V. • The Program Management Model: This model describes the way in which each AFF provider agency operationalized the policy guidelines, designed their initiative to meet State requirements, and responded to the unique characteristics of their locality and the needs of their program participants. In the First Annual Evaluation Report, findings from site visits that assessed the program management models of the nine AFF provider agencies were reported, including the administrative structure of the AFF provider agencies; compensation for services and provider rates; staff qualifications and training issues; and linkages to provide supportive services for clients. Subsequent Quarterly Evaluation Reports throughout the first year of the program reported on different aspects of the Program Management Model being implemented by AFF provider agencies. • The Operations Model: This model consists of the dual perspectives of frontline staff and program participants in describing program operations. Key questions of the frontline staff subcomponent of the model concern whether staff are implementing the program according to the Program Management Model, and, if not, “Why not?” The participant issues sub-component of the model identifies participant perspectives and descriptive data on participant needs and actual receipt of services. It also identifies how satisfied participants are with services, how well the vision statement is operationalized in terms of the participants’ experiences (e.g., are services available to them, accessible, and can they receive them in a timely manner?), and whether or not there are unmet needs. 5 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 • Description of Families F.I.R.S.T. Clients Outcomes: The evaluation framework developed to study AFF provides an examination of the program effectiveness at the participant level as well as the systems level. Participant-level outcomes include changes that occur after utilization of program services, specified in Chapter I as performance measures (e.g., reduced re-allegations of child abuse and neglect, attainment of employment, decrease in alcohol/drug use, reduced time in foster care, increase in reunifications from foster care). System-level outcomes include changes in the service delivery systems in communities (e.g., availability, timeliness, and accessibility of substance abuse treatment services) which in turn can influence participant-level outcomes such as child safety, family stability, permanency for children in foster care, the achievement of self-sufficiency through employment, and recovery from alcohol and drug problems. Other systems-level outcomes can include systems change at the local as well as state level (e.g., increased coordination between agencies). Exhibit II-1 provides an overview of the Evaluation Framework. This framework summarizes the models described above, upon which the evaluation is built. The framework provides a description of the system components at various points in time and from the perceptions of different stakeholders. It serves as a map or guide for how the major activities of the AFF process and outcome studies fit together into an overall program evaluation. For the current annual report, much of the data presented addresses the Operations Model with some information (i.e., preliminary findings on systems-level changes) addressing the Outcomes component of the evaluation framework. 6 • Population to be served as defined by legislation • ADES requirements • Coordination of Treatment Fund Participant Issues • Characteristics of AFF participating clients • Services actually received by participating clients • Client satisfaction with services Outcomes 7 Systems Level Outcome Goals: • Increase timeliness, availability and accessibility of substance abuse treatment to improve child safety, family stability, and permanency for children in out of home placement, with preference for reunification with birth family • To achieve self-sufficiency through employment • To promote recovery from alcohol and drug problems • Other: Increased coordination at community and state level Participant Level Performance Measures: • Reduce recurrence of child abuse and/or neglect • Increase the number of families obtaining or maintaining employment • Decrease the frequency of alcohol and/or drug use • Decrease the number of days in foster care per child • Increase the number of children in out of home care who achieve permanency Operations Model Front-Line Staff Issues • Staff perceptions and expectations of targeted population • Staff approach to implementing services • Staff perceptions of actual service coordination Program Management Model • Target population • AFF provider agency’s configuration of service delivery system • Planned approach to coordinating services Policy Model Exhibit II-1 Arizona Families F.I.R.S.T. Evaluation Framework Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2004 Overview of Evaluation Framework CHAPTER III DESCRIPTION OF ARIZONA FAMILIES F.I.R.S.T. CLIENTS AND SERVICES RECEIVED In this section of the annual report, we present available data on the characteristics of individuals referred to Arizona Families F.I.R.S.T. (AFF) during the first year of the program; characteristics of clients who actually enrolled in the program; service activity data, including referrals, assessments, service plans, engagement in treatment services, types of treatment services utilized; and length of time that participating clients spent in treatment. This section also includes implementation findings from data collected onsite with respect to referrals, assessments, service planning, and treatment in order to better understand the service trends that emerged from the client data. Findings are summarized using tables, charts and summary bullet points. The section pertaining to service activity includes more detailed narrative discussion because of the qualitative research findings that have been incorporated into the chapter. In the exhibits that follow, percentages are reported in the body of the tables to allow for comparisons across the AFF provider agencies, and Statewide percentages are reported in the column labeled “All Sites.” In a few exceptions, frequency data are reported instead of percentages to more effectively convey findings. The exhibits presented in this chapter on descriptive information pertaining to age, sex, and race report percentages with adjustments for unknown/missing data so that the percentages for referred and participating clients can be compared.1 A. Characteristics of Individuals Referred In this section, data are presented on characteristics of individuals referred to AFF, for all individuals referred since the program’s inception in March 2001 through March 31, 2002.2 The information available on referred individuals is more limited than the data available on participating clients. The key findings from the exhibits are summarized in bullet form following each exhibit. Exhibit III-1 Age of Individuals Referred: Project Inception - March 31, 2002 (n = 1447) Provider Site AZPAC AZPAC AZPAC Coconino Yavapai Yuma West Old Horizon Concho SEABHS TERROS Care All Sites n=5 Under 18 years 0% 0% 0% 1% 0% 0% 0% 1% 0% (0.4%) n=354 18-25 years 26% 28% 17% 26% 30% 19% 17% 27% 23% (26%) n=489 26-33 years 19% 28% 39% 38% 37% 30% 42% 37% 18% (36% n=388 34-41 years 33% 30% 39% 27% 29% 37% 30% 27% 31% (28%) n=137 42+ years 22% 14% 6% 9% 5% 14% 11% 8% 28% (10%) Total n=27 n=81 n=18 n=380 n=84 n=91 n=53 n=600 n=39 N=1,373 Note: For 74 individuals, data were missing on age. Percentages are based on adjustments for unknown age. Age CPSA • 26 percent of the individuals referred were between the ages of 18 and 25 years, 36 percent were between 26 and 33 years old, 28 percent were from 34 to 41 years of age, and 10 percent of persons referred were age 42 or older. 1 The percent of unknown/missing data for each variable is presented so that readers can understand the extent to which data were not available. For exhibits that report data other than age, sex, and race, the total N’s remain constant and we present the percent of unknown/missing data, where relevant. 2 While the majority of AFF provider agencies began implementation of their programs in March 2001, data on referrals indicate that some referrals were received prior to March 2001. Thus, tables that present referral data for the overall year-todate were labeled “project inception – March 31, 2002”) 8 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients Exhibit III-2 Sex of Individuals Referred: Project Inception – March 31, 2002 (n = 1447) Provider Site AZPAC AZPAC AZPAC Old Gender Coconino Yavapai Yuma CPSA Horizon Concho SEABHS TERROS WestCare All Sites n=354 Male 30% 31% 33% 29% 19% 27% 28% 22% 26% (26%) n=1,028 Female 70% 69% 67% 71% 81% 73% 72% 78% 74% (74%) Total n=27 n=85 n=18 n=401 n=63 n=91 n=53 n=605 n=39 N=1,382 Note: For 65 individuals, data were missing on sex. Percentages are based on adjustments for unknown sex. • Seventy four percent of persons referred were female, 26 percent were male. Exhibit III-3 Race of Individuals Referred: Project Inception - March 31, 2002 (n = 1447) Race/Ethnicity of Clients Referred by Provider Site 100% 80% 60% 40% 20% 0% es W re OS a tC RR TE HS ho a m Yu ai o in on p va Ya c Co nc Co AB SE d Ol on r iz Ho C C C Black SA CP PA AZ PA AZ PA AZ White Hispanic Native American /Alaska Native Asian/Pacific Islander Other • Statewide, 60 percent of individuals referred to AFF were White, 14 percent were Black, 18 percent were Hispanic, and Native American/Alaska Natives accounted for 5 percent of referrals. • For 104 individuals referred, data was missing on their race. B. Characteristics of AFF Participating Clients Clients were considered to be participating clients if they had a service plan developed. This definition was developed in the analysis plan for the evaluation to ensure that the clients followed in the outcome study were individuals who had actually enrolled in the program. Hence, enrollment is indicated when a service plan has been developed. The following data on characteristics of AFF participating clients includes those individuals who had a service 9 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients plan developed during the first year of the program (i.e., any time between March 2001 and March 31, 2002). 1. Demographic Characteristics The first set of exhibits in this section report on descriptive information about participating clients, including their age, sex, race, number of children, education level, employment status and marital status. Each exhibit is followed by a summary of the information reported using summary bullet points. a. Age and Sex The following data report on age and sex of clients participating in AFF. Exhibit III-4 Age of Participating Clients: March 2001 - March 31, 2002 (n=803 participating clients) Provider Site Old AZPAC AZPAC AZPAC Coconino Yavapai Yuma CPSA Horizon Concho SEABHS TERROS WestCare All Sites n=2 Under 18 years 0% 0% 0% 0.4% 0% 0% 0% 0.3% 0% (0.3%) n=174 18-25 years 21% 24% 9% 23% 27% 18% 15% 22% 7% (22%) n=293 26-33 years 21% 30% 36% 38% 29% 32% 43% 40% 7% (37%) n=244 34-41 years 32% 30% 45% 28% 34% 43% 30% 29% 71% (31%) n=83 42+ years 26% 15% 9% 10% 10% 7% 13% 9% 14% (10%) Age Total n=19 n=66 n=11 n=252 n=41 n=28 n=47 n=318 n=14 N=796 Note: For 7 individuals, data were missing on age. • Of the participating clients (i.e., those with a service plan by March 31, 2002) 22 percent were between 18 and 25 years old; 37 percent were between 26 and 33 years; 31 percent were from 34 to 41 years of age; and 10 percent were 42 years and older. • The patterns with respect to age of participating clients were similar to the ages of individuals referred to the program. Within AFF sites, age of participants showed a similar pattern to the age of referred individuals. The exception was WestCare, where referred clients were distributed across age categories but among participating clients, 71 percent were from 34 to 41 years old (the overall number of participants at WestCare, however, is only 14). Exhibit III-5 Sex of Participating Clients: March 2001 – March 31, 2002 (n=803 participating clients) Gender Male Female Provider Site AZPAC AZPAC AZPAC Old Coconino Yavapai Yuma CPSA Horizon Concho SEABHS TERROS WestCare All Sites n=197 21% 29% 18% 32% 19% 18% 26% 20% 21% (25%) n=602 79% 71% 82% 68% 81% 82% 74% 80% 79% (75%) Total n=19 n=66 n=11 n=257 Note: For47 individuals, data were missing on sex. n=37 10 n=28 n=47 n=320 n=14 N=799 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients • Seventy five percent of participating clients were female, and 25 percent were male, reflecting a pattern that was similar to those who were referred to AFF. b. Race The exhibit that follows presents information on race of AFF participating clients. Exhibit III-6 Race of Participating Clients: March 2001 – March 31, 2002 (n=803 participating clients) Race/Ethnicity of Participating Clients by Provider Site 100% 80% 60% 40% 20% 0% Native American /Alaska Native e ar tC es W OS RR TE ma Yu Hispanic HS AB SE o ch on dC Ol on riz Ho SA CP i pa va Ya o nin co Co Black C PA AZ C PA AZ C PA AZ White Other • With respect to race/ethnicity of participating clients, overall, 62 percent of participants were White, 14 percent were Black, 18 percent were Hispanic, and 6 percent were Native American/Alaskan Native.3 There was both within-site and cross-site variation regarding the race of participating clients. • In general, the racial distribution of clients engaged in AFF was similar to the racial distribution of clients referred to the program (e.g., 27 percent of TERROS’ referrals were Black, and 27 percent of TERROS’ participants were Black; 29 percent of the referrals at CPSA were Hispanic, and approximately 30 percent of CPSA’s participants were Hispanic). • Hispanics: Almost one-half of AZPAC Yuma’s participants were Hispanic (45%). However, due to the low number of referrals at AZPAC Yuma, this site accounted for only three percent of Hispanic participants cross-site. CPSA accounted for more than half (52%) of Hispanic participants cross-site. • Blacks: Over one-quarter (27%) of the participating clients served by TERROS wee Black, which accounted for almost 80 percent of all Black participants across sites. 3 According to 1999 ADES data, the overall racial composition of Arizona’s general child welfare population is 55.7 percent White, 3.4 percent Black, 31.8 percent Hispanic, 7.1 percent Native American/Alaskan Native, and two percent Asian/Pacific Islander. 11 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients • Whites: More than one-half of the participants at each of the nine AFF provider sites were White. One hundred percent of the participating clients served by WestCare were White. However, this provider agency serves a small number of clients and it accounted for only three percent of the total Whites participating in AFF. • Native Americans: Over one-quarter of the participating clients served by AZPAC Coconino were Native American (26%), accounting for 11 percent of Native Americans cross-site. CPSA and TERROS accounted for three-quarters of all Native Americans served by the AFF program. However, come of the other AFF provider agencies that served smaller numbers of clients, such as Old Concho, also had a large proportion of participating clients who were Native American (14% of Old Concho’s participating clients were native American, accounting for 9% of Native Americans across sites. 2. Family Size and Marital Status The following exhibits report on family size and marital status among participating clients. Family size is presented in terms of the number of children in participating families. Exhibit III-7 Number of Children in Participating Families: March 2001 – March 31, 2002 (n=636 participating families) Number of Children in Participating Families 5or more children 16% 1 child 27% 4 children 10% 3 children 20% 2 children 27% Note: For 69 families, data were missing on the number of children in the family • Overall, among the 636 participating families, there was variation in family size with respect to the number of children in families. • Twenty seven percent of participating families had only one child; another 27 percent of families had two children; 20 percent had three children; and 10 percent of participating families had four children. • Statewide, 16 percent of families accounted for those with five or more children. 12 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients Exhibit III-8 Marital Status of Participating Clients: March 1, 2001 - March 2002 Marital Status Married Provider Site AZPAC AZPAC AZPAC Old West Coconino Yavapai Yuma CPSA Horizon Concho SEABHS TERROS Care 32% 20% 27% 12% 27% 11% 32% 19% 29% 5% 3% 0% 4% 0% 7% 0% 2% 0% Never Married 37% 45% 64% 35% 32% 7% 34% 56% 29% Separated/ Divorced/ Widowed 16% 24% 9% 14% 32% 18% 32% 16% 36% Unknown/ Missing 11% 8% 0% 35% 10% 57% 2% 8% 7% n=19 n=66 n=11 n=257 n=41 n=28 n=47 n=320 Consensual Total n=14 All Sites n=146 (18%) N=22 (3%) n=346 (43%) n=145 (18%) n=144 (18%) N=803 • Overall, 18 percent of participating clients were married. • Sixty one percent of participants were not married. In specific, 43 percent of the participating clients overall had never been married, and 18 percent of clients across sites were separated, divorced, or widowed. • Marital status was not known for 18 percent of the participating clients. 3. Education Level and Employment The following two exhibits report on the highest education level attained by participating clients and the employment status of participating clients. Exhibit III-9 Highest Education Level Attained by Participating Clients: March 2001 - March 31, 2002 Provider Site AZPAC Education Coconino Level Attained Less than High School 32% Diploma/Certificate GED High School Diploma Vocational Education Certificate College Associate Degree College Bachelor Degree College Advanced Degree Unknown Total • AZPAC AZPAC Yavapai Yuma CPSA Old West Horizon Concho SEABHS TERROS Care 38% 36% 43% 54% 25% 26% 51% 21% 0% 11% 36% 11% 10% 0% 17% 0% 0% 63% 30% 27% 26% 17% 18% 40% 20% 57% 5% 3% 0% 0% 5% 0% 0% 0% 0% 0% 5% 0% 9% 5% 0% 2% 10% 7% 0% 5% 0% 0.4% 0% 0% 0% 1% 0% 0% 3% 0% 1% 0% 0% 0% 3% 0% 0% 6% 0% 9% 10% 57% 15% 15% 14% n=66 n=11 n=41 n=28 n=320 n=14 n=19 n=257 n=47 All Sites n=352 (44%) n=52 (6%) n=206 (26%) n=5 (1%) n=63 (8%) n=7 (1%) n=13 (2%) n=105 (13%) N=803 Overall, 44 percent of total participating clients across AFF sites did not complete high school. This pattern was consistent across sites—for clients served by both urban and rural provider agencies. 13 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients • For 32 percent of participating clients, a high school diploma or GED was the highest education level attained. • TERROS and CPSA accounted for almost 90 percent of the participating clients with an Associate’s degree. • TERROS and AZPAC Yavapai accounted for 86 percent of all clients whose highest education was a Bachelor’s degree. • For 13 percent of the participating clients, information was not available on their education level. Exhibit III-10 Employment Status of Participating Clients: March 2001 - March 31, 2002 Provider Site Employment Status Employed Full Time Employed Part Time AZPAC Coconino AZPAC Yavapai AZPAC Yuma 21% 23% 27% 41% 15% 14% 28% 17% 21% 21% 12% 0% 11% 7% 0% 9% 4% 0% Work Activity* Educational/ Training ** Activities 0% 0% 0% 4% 2% 0% 0% 3% 0% 0% 0% 9% 2% 0% 0% 4% 2% 0% Not Employed 53% 59% 64% 31% 66% 29% 57% 58% 50% Unknown 5% 6% 0% 12% 10% 57% 2% 15% 29% n=13 (2%) n=391 (49%) n=110 (14%) n=19 n=66 n=11 n=257 n=41 n=28 n=47 n=320 n=14 N=803 Total Old West CPSA Horizon Concho SEABHS TERROS Care All Sites n=209 (26%) n=60 (7%) n=20 (2%) ** Work activities include transitional employment, community-based work, facilities-based work activities, and sheltered employment. ** Educational/training activities include education/training, social drop-in/recreational activities, and volunteer. • Across AFF sites, 26 percent of participating clients were employed full-time; 7 percent were employed part-time; and 49 percent of clients were not employed. • Four percent of clients were involved in a work activity or educational training. • For the participating clients served at the two largest urban AFF sites (CPSA and TERROS), 41 percent of the CPSA clients were employed full-time but only 17 percent of the TERROS clients worked full-time. 14 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients 4. Title XIX Participants Exhibit III-11 presents data on the Title XIX status (i.e., enrollment in Medicaid) for AFF participating clients. Exhibit III-11 Title XIX Status of Participating Clients: March 2001 - March 31, 2002 (n=803 participating clients) Title XIX Status of Participating Clients by Provider Site 100% 80% 60% 40% 20% 0% W R e S* ar O R o ch S* on H B A C m a on i o in pa va Yu Ya oc C * on tC es TE SE ld O iz or H * A C A C A C A PS C ZP A ZP A ZP A Title XIX Clients Non-Title XIX Clients Unknown *Title XIX Provider • Overall, 58 percent of participating clients were Title XIX (i.e., enrolled in Medicaid); 34 percent were non-Title XIX. • For eight percent of participating clients, Title XIX status was not known. • With respect to site variation, AZPAC Yuma had the lowest percentage of Title XIX participating clients (36%) compared to the other AFF provider agencies. AZPAC Yuma is not a Title XIX provider and therefore must refer Title XIX clients to a RBHA subcontractor for services. • Horizon had the highest percentage of Title XIX clients (73%) compared to the other provider agencies. Horizon is a RBHA subcontractor. • For the other AFF provider agencies, the percentage of Title XIX participating clients ranged from 58 percent to 64 percent. 15 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients 5. Substance Abuse The remaining three exhibits in this section address the probability of substance dependence4, reported use of various drugs at AFF enrollment, and poly-drug co morbidity patterns among AFF participating clients. Similar to the presentation format used in this chapter, key findings from each of the exhibits are discussed in summary bullets. Exhibit III-12 Probability of Substance Dependence Among Participating Clients: March 2001 – March 31, 2002 Probability of Substance Dependence Provider Site AZPAC AZPAC AZPAC Old West CPSA Horizon SEABHS TERROS Coconino Yavapai Yuma Concho Care High Probability 5% 42% 91% 58% 51% 93% 36% 43% 43% Low Probability 21% 12% 9% 25% 7% 4% 28% 22% 0% Missing 74% 45% 0% 18% 41% 4% 36% 36% 57% Total n=19 n=66 n=11 n=257 n=41 n=28 n=47 n=320 n=14 All Sites n=394 (49%) n=163 (20%) n=246 (31%) n=803 Note: Based on data from the Substance Abuse Subtle Screening Inventory, administered during the first year of the program to screen for presence of a substance abuse disorder. The SASSI-3 screens for substance dependence even if individuals do not acknowledge misuse of substances or symptoms associated with it. • Data from the SASSI-3 indicates that, overall, 49 percent of participating clients had a high probability of substance dependence. The SASSI-3 is only one part of a comprehensive assessment that is completed with clients; the full assessment also includes a biopsychosocial assessment and a family centered interview. • Data were missing from almost one-third of participants, which limits the ability to draw further conclusions or interpretations regarding the probability of substance dependence among clients.5 4 Substance dependence, according to the SASSI Institute, is a primary, pervasive, progressive disorder that has a negative impact on individuals, significant others, and society. 5 Beginning in March 2002, ADES replaced the SASSI-3 screening measure with the Addiction Severity Index-Lite version, an assessment tool which can be used to assess change in clients over time on several dimensions related to recovery and which has been used widely in the field of substance abuse research. 16 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients Exhibit III-13 Percent of Participating Clients Using Drugs at Enrollment: March 2001 – March 31, 2002 Provider Site AZPAC Coconino AZPAC Yavapai AZPAC Yuma Alcohol 84% 64% 55% Tobacco 5% 9% 0% Cocaine 5% 23% 0% 32% 73% 9% Heroin/ Morphine 0% 11% 0% Methamphetamine 16% 79% 82% Marijuana Total n=19 n=66 Old West All CPSA Horizon Concho SEABHS TERROS Care Sites n=499 78% 41% 82% 79% 48% 43% 62% n= 47 6% 5% 43% 0% 3% 7% 6% n=296 65% 10% 4% 21% 30% 0% 37% n=391 74% 20% 7% 60% 33% 36% 49% n=47 11% 0% 0% 0% 3% 0% 6% n=338 34% 56% 43% 47% 38% 71% 42% n=257 n=41 n=28 n=47 n=320 n=14 n=803 n=11 Note: This table includes drugs that clients were actively using at the time of their enrollment in AFF. If a client had not used a drug in the past 30 days, this was not included. Percentages reported are not based on mutually exclusive categories (i.e., the same client, if using multiple drugs, was reported in more than one category). Information on type of drug(s) being used was available for 87% of participating clients. • Overall, 62 percent of participating clients reportedly used alcohol. • Forty nine percent of clients reportedly used marijuana. • Thirty seven percent of participants indicated that they used cocaine. • Methamphetamine use was reported by 42 percent of participating clients. • Six percent of clients used heroin/morphine. • Eight percent of clients used other hallucinogens; for other drug types, including inhalants, barbiturates, other stimulants, and other narcotics, the rate was approximately two percent. • The data substantiate the pervasive alcohol and methamphetamine problem that AFF provider agencies discussed during site visits. • With respect to site variation, use of cocaine was highest at CPSA, where 65 percent of participating clients reportedly used cocaine. Since CPSA is one of the largest provider sites, it accounts for most of the statewide cocaine use. • The highest rates of marijuana use were reported by CPSA (74%), AZPAC Yavapai (73%), and SEABHS (60%). • Four AFF provider agencies (AZPAC Coconino, CPSA, Old Concho, and SEABHS) reported that 78 percent or more of their participating clients used alcohol. • The rate of methamphetamine use was over 50 percent at four of the AFF sites: AZPAC Yavapai (79%); AZPAC Yuma (82%); Horizon (56%); and WestCare (71%). 17 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients Exhibit III-14 Poly-Drug Co-Morbidity Patterns Among Participating Clients: March 2001 – March 31, 2002 (n = 803 participating clients) Poly-Drug Co-Morbidity 100% 80% 69% 63% 60% 50% 46% 52% 47% 39% 40% 43% 30% 28% 21% 20% 10% 0% Alcohol (n=222) Alcohol Methamphetamine (n=206) Marijuana (n=67) Methamphetamine Marijuana Cocaine (n=160) Cocaine Poly-drug co-morbidity was examined for clients who reported usage of more than one drug type. On the basis of either exclusive use of one drug type or most frequent usage of a particular drug, “frequent drug type” categories were identified. The four most frequently used substances were alcohol, methamphetamine, marijuana, and cocaine. Within each of these frequent drug use categories, multiple drug use patterns were examined with respect to other types of drugs that clients reported using in addition to their most frequently used substance. • Twenty eight percent of participating clients reported that alcohol was their exclusive or most frequently used substance. Among this group, 46 percent also reported using marijuana. • Twenty six percent of participants reported that methamphetamine was their most frequently used substance, and among this group, 50 percent also used alcohol and 47 percent also used marijuana. • Among the eight percent of clients whose most frequently used drug was marijuana, 43 percent also reported use of cocaine. • Twenty percent of participating clients reported that their most frequently used drug was cocaine. Among these clients, 70 percent also used alcohol and 63 percent also used marijuana. 18 Evaluation of Arizona Families F.I.R.S.T. – Annual Report 2002 Description of Families F.I.R.S.T. Clients One potential interpretation of the drug combination patterns observed is that clients may be using additional drugs as the effects of their most frequently used drug recede. For example, the effects of methamphetamine typically last more than 10 hours and the half-life6 is 12 hours, while cocaine’s high lasts about 20 to 30 minutes, with a half-life of approximately one hour.7 It is possible that alcohol and marijuana may be used as transition substances by the AFF clients who are frequent methamphetamine and cocaine users. C. Service Activity The information on service activity includes referral and assessment trends over the first year of the program; levels of engagement in treatment services; definitions of primary treatment level groups and the types of treatment received by participating clients; and length of time that participating clients spent in treatment. 1. Referrals Exhibit III-15 presents data on the number of referrals to AFF during the first year of the program. The data indicate that Statewide, the number of referrals was generally constant across quarters, averaging about 345 referrals per quarter. Exhibit III-15 Number of Referrals by Quarter: Project inception through March 31, 2002 Provider Site AZPAC AZPAC Quarter Coconino Yavapai