Evaluation of Arizona Families F.I.R.S.T. Annual Evaluation Report Submitted on: December 17, 2003 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 ACKNOWLEDGEMENTS The authors wish to thank staff of the Arizona Department of Economic Security and the Arizona Department of Health Services for their ongoing cooperation and assistance with the evaluation. In particular, Nancy Hansen and Mark McCain, of ADES, and Christy Dye and Cora Bagley, of ADHS have been helpful throughout the course of the evaluation. We also thank Dr. Hank Radda, former Substance Abuse Administrator at ADES, for his support and cooperation. Thanks are extended as well to the staff of LeCroy and Milligan Associates for their work in conducting client focus groups. This work was completed under ADES contract number E4371670. i 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) 8881 (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 past two years of program operations, 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 Regional Behavioral Health Authority (RBHA) providers when the AFF client was in the Title XIX program. Provider agencies also have worked to promote a more family-centered service delivery system and engage and retain clients in treatment. 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. During the second year of the evaluation, the focus was on continuing to document program implementation through the analysis and reporting of clientlevel service utilization data and qualitative data gathered from program directors, RBHA representatives, and clients. Analyses also were conducted using the data available to determine early findings with respect to child welfare and employment outcomes as of March 31, 2003. Overview of Annual Evaluation Report This report presents service utilization data for the annual reporting period that covers April 1, 2002 through March 31, 2003. It includes process data collected for the period of April 1, 2002 through June 30, 2003. The evaluation data have contributed to an understanding of the characteristics of AFF participating clients; the types of drugs used by clients across the ii nine AFF provider sites, including poly-drug use patterns; referral trends; levels of client engagement in services and service utilization patterns; and lengths of stay in treatment. Process data presented in last year's Annual Evaluation Report (December 2002) offer findings with respect to changes in the timeliness, availability, and accessibility of treatment services as perceived by AFF program directors. In the current annual report, process data collected through telephone interviews with AFF program directors indicate that most AFF provider agencies have continued to work on their existing collaborative partnerships in order to increase their partners’ understanding of AFF services and to better coordinate service delivery to clients. For some program directors, however, the uncertainty regarding future funding for AFF and the continuation of the program became an issue that interfered with activities to move their programs forward in areas such as program development and building new collaborative partners. Early results related to treatment and recovery reported in this annual report include the findings that AFF clients are engaged in treatment services at a high rate and are spending several months in treatment services. These are encouraging results because retention of clients in treatment services to address their needs is an intermediary outcome in the recovery process. Early outcomes in the area of child welfare and employment provide benchmarks for the AFF population from which subsequent analyses and comparisons can be made in the future. Prior to analyzing these data, benchmarks were not available for the specialized AFF population. 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, 82 percent of participating clients were in the Title XIX program (i.e., enrolled in Medicaid) and 18 percent were non-Title XIX. • Seventy five percent of participating clients were female, and 25 percent were male. Twenty eight percent were between 18 and 25 years old; 35 percent were between 26 and 33 years; 26 percent were from 34 to 41 years of age; and 10 percent were 42 years and older. • Overall, 67 percent of participants were White, 15 percent were Hispanic, eight percent were Black, five percent were Asian/Pacific Islander, and four percent were Native American/Alaskan Native. Overall, the racial distribution of clients engaged in the program was similar to the racial distribution of referred clients. • Overall, 24 percent of participating clients across AFF sites did not complete high school. This pattern was consistent across sites with the exception of TERROS, the largest AFF provider site, where only 14 percent of clients did not complete high school. What Do We Know About Drug Use Among AFF Clients? • 1 With respect to drug use reported at the time of enrollment in AFF1, alcohol was reportedly used by 42 percent of participating clients statewide; marijuana was used by Drug use at enrollment was measured by whether clients reported use of a substance within the past 30 days. iii 36 percent of clients; methamphetamine was reportedly used by 28 percent of clients statewide; cocaine was used by 24 percent of participating clients; and heroin/morphine was used by 4 percent of clients. Use of cocaine was highest at CPSA (where cocaine was used by 63% of clients); the highest rates of marijuana use were reported by AZPAC Yavapai (71%), CPSA (66%), and SEABHS (67%). Methamphetamine was used by over 65 percent of participating clients at AZPAC Yavapai (73%), AZPAC Yuma (68%), and WestCare (72%). • The polydrug comorbidity patterns among participating clients indicated that for the 419 participants who reported that methamphetamine was their most frequently used substance, 47 percent also used alcohol and 48 percent also used marijuana. Approximately 474 participating clients reported that alcohol was their most frequently used substance. Among this group, 49 percent also reported using marijuana. Among the 320 participating clients reporting cocaine as their most frequent drug, 60 percent also used marijuana and 64 percent also used alcohol. What has been the Pattern of Referrals to AFF? • Eight of the AFF provider agencies (AZPAC Coconino, AZPAC Yavapai, AZPAC Yuma, CPSA, Horizon, Old Concho, TERROS and WestCare) showed fluctuation in the number of referrals over the quarters and an overall increase in referrals from July through December 2002. From December 2002 to March 2003, seven providers showed an increase in referrals again, but CPSA and WestCare showed a decrease. • Referrals from TERROS doubled during the last few quarters, increasing from 184 referrals during July – September 2002 to 359 referrals during October – December 2002, then increasing to 469 referrals during January - March 2003. TERROS’ program directors believe this increase is due to the new State policy regarding Substance Exposed Newborns as well as anticipation of the closing of a major treatment provider in District I, which has resulted in greater numbers of clients being referred to TERROS. To What Extent are AFF Clients Engaged in Substance Abuse Treatment? • Engagement in treatment services was one of the Steering Committee's2 suggested performance measures. Sixty eight percent of all clients referred to AFF in the annual reporting period (April 1, 2002 - March 31, 2003) were subsequently engaged in treatment services. Engagement in treatment may 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 AFF provider agencies (AZPAC Coconino, AZPAC Yavapai, Horizon, Old Concho, SEABHS, TERROS and WestCare) completed assessments on more than 70 percent of their referred clients. AZPAC Yuma and CPSA completed assessments on 67 percent and 58 percent, respectively, of referred clients. • At seven of the AFF sites, there was a consistent pattern, whereby 100 percent of clients with a service plan went on to receive treatment services. 2 The AFF Steering Committee was formed as a policy committee to provide guidance and oversight to AFF. The Steering Committee initially took on the role of specifying policies and requirements to help shape the direction of the program and reviewing implementation procedures. iv • Several AFF program directors (TERROS, AZPAC Yavapai, AZPAC Yuma, and Horizon) noted that CPS-involved clients whose substance abuse treatment is court mandated are more likely to become engaged in treatment than non-mandated treatment cases referred by CPS or non-CPS involved cases. • Several AFF program directors (SEABHS, CPSA, AZPAC Coconino, and AZPAC Yuma) noted that the initial outreach and quality of the first contact with the client is a good indicator of whether a client will become engaged in treatment. A unique component of the AFF program is its emphasis on outreach and the allocation of resources to provider agencies to make multiple outreach attempts. AFF provider agencies are required to make the first outreach attempt within 24 hours of receiving a client’s referral to their program. AFF provider agencies are also required to make at least three physical attempts to contact the client during the outreach phase. To What Extent are AFF Clients Staying in Treatment Services? • With respect to length of stay in treatment, among the clients who were participating in treatment during the annual reporting period, 45 percent of clients with an opportunity to spend at least six months in treatment remained in treatment for six months or longer. In addition, 22 percent of clients who received treatment during this reporting period had been in treatment for 8 months or longer. These patterns are promising given that research on substance abuse treatment emphasizes that the longer a client remains in treatment, the more likely it is that the treatment will result in long-term behavior change.3 • Several AFF program directors (TERROS, AZPAC Coconino, AZPAC Yavapai) perceived that CPS-involved clients with court-mandated treatment are more likely to remain in treatment than those clients who are not involved with CPS. TERROS' program director noted that clients referred by CPS are motivated to stay in treatment in order to retain their children in the home, or, if their children have been removed, to be reunified with their children. What are some of the Early Outcomes in Child Welfare and Employment, based on Available Data? • Among the 2,122 CPS families participating in AFF during the annual reporting period, 92 percent had not experienced a subsequent substantiated report of abuse or neglect when their status was six months after enrolling in AFF. • Two cohorts of families were analyzed-- one with a 12 month opportunity (or longer) to receive treatment, and the other with a 6 - 12 month opportunity to receive treatment. Treatment opportunity is based on when caregivers enrolled in AFF and the date when their status was examined--March 31, 2003. Among the children placed in care after AFF enrollment, the cohorts showed the same reunification rate (17%). Also, children whose caregivers had a 12 month treatment opportunity in AFF remained in care a median of 148 days, and children whose caregivers had a six month treatment opportunity in AFF spent a median of 185 days in care. 3 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. v • Ninety seven percent of AFF participating clients who were employed at the time of their enrollment in AFF maintained their employment status through March 31, 2003, and 25 percent of unemployed clients obtained employment. • If additional data from providers are made available in the future that address baseline severity of primary drug used, presence of co-occurring conditions, whether treatment was completed, and indicators of recovery through the ASI-lite,4 further interpretation of the outcomes data will be possible. What Characteristics are Perceived to be Associated with Client Recovery ? • AFF program directors most frequently reported that CPS involvement was a key factor associated with client success in treatment. In specific, five out of nine AFF program directors (TERROS, AZPAC Yavapai, Horizon, SEABHS, and AZPAC Yuma) noted that clients who have lost their children to foster care or have a potential to lose their children are more likely to be motivated to succeed. As described by one program director, "Moms who want their kids back are the most likely to succeed." • Other client characteristics perceived by AFF program directors to contribute to client success were (1) employed clients are more likely to succeed in recovery than unemployed clients; (2) older clients are more likely to succeed in recovery than younger clients due to their emotional maturity; (3) having a family support network and community support, including support groups, is integral to client success; and (4) clients that had permanent housing are more likely to succeed than homeless clients. What Do We Know About Clients’ Satisfaction and Experiences with AFF? • Focus groups were conducted to gather information from AFF clients on their experiences in the program. Clients from the majority of AFF provider agencies reported that they played a role in the development of their treatment plan. Clients across the AFF sites discussed the value of participating in group treatment and “not feeling alone.” Clients reported that they trusted the staff, felt comfortable talking with them, felt they were knowledgeable and caring. • Clients reported that their treatment therapists discussed their progress with case managers regularly and that this was helpful in coordinating appropriate services. Clients also indicated that the positive feedback and encouragement they received from staff gave them an incentive to comply with their treatment. • In general, clients reported that they were receiving the services they needed but indicated there were other services that were needed in their communities, including transitional housing (AZPAC Yavapai), parenting classes and child care (Horizon), couples counseling and domestic violence classes (CPSA), family sessions and home visits (SEABHS), and housing and group classes for men (TERROS). 4 The Addiction Severity Index (ASI)-lite, a shorter version of the standard ASI, is a semi-structured interview designed to assess six potential problem areas that address a range of factors related to recovery. As part of the approved AFF evaluation plan, providers were responsible for collecting baseline and follow-up assessment data on clients using the ASI-lite and supplying this data for the evaluation. vi What Other Lessons Have Been Learned After the Second Year of the Program? • Program directors reported that the successes experienced to date with respect to implementation of AFF include increased collaboration among service providers, CPS, and /or the RBHA; the use of outreach and engagement services to get clients into treatment; the ability to provide support services to meet basic client needs and to increase clients' access to substance abuse treatment; and implementation of client and family-centered services. • RBHA representatives identified several factors that had contributed to effective collaboration with AFF providers and implementation of the AFF program. These included (1) RBHA representatives in attendance at AFF collaborative meetings and participation in cross-agency training; (2) multi-agency case staffings in which both the AFF provider and RBHA treatment staff participate; (3) coordination with the AFF provider to determine Title XIX eligibility; (4) the availability of additional substance abuse treatment staff at the RBHA agency; and (5) a centralized referral process for handling substance abuse cases at the RBHA agency. • AFF program directors noted the following barriers to client success: the challenges of living in rural areas where clients are isolated and do not have easy access to transportation; differing perspectives and philosophies among agencies regarding treatment; lack of housing for clients, and lack of employment opportunities that paid enough to meet clients' needs. • The most frequently cited challenge reported by AFF program directors in the implementation of AFF was concern regarding budget issues and the ability to continue operating a program within the context of uncertain funding from year to year. Other challenges included the lack of residential care in the community; managing a high level of referrals each month; lack of transportation in rural areas; and a shortage of transitional housing. • With respect to evaluation, continued evaluation efforts with the AFF program should emphasize strong data management at the provider level, the ability to enforce providers to supply evaluation data, and the ability to integrate data from multiple platforms at the State and provider levels. Conclusion Overall, information presented in this report indicates that by the end of the annual reporting period, referrals to AFF were at an all-time high. This was occurring at the same time that uncertainties regarding the future funding of the program caused some of the AFF program directors to delay moving forward in building new collaborative partnerships and expanding their program development activities. Levels of engagement in treatment continue to be high for AFF clients, with 68 percent of all referrals to the program this past year ending up in treatment and 98 percent of clients with a service plan developed receiving some treatment services. Findings on retention in treatment indicate that clients participating in treatment during the annual reporting period are remaining in treatment for several months, which is an expected proximal outcome prior to recovery. The early outcomes data have provided some general benchmarks for the AFF population with vii respect to subsequent substantiated reports of abuse and neglect, reunification, time spent in foster care, maintaining employment status, and gaining employment. Process data gathered from clients suggests that the coordination among staff and clients' relationships with treatment staff have been important in helping clients obtain the services they need and to comply with their treatment plan. viii TABLE OF CONTENTS PAGE ACKKNOWLEDGEMENTS........................................................................................................... i EXECUTIVE SUMMARY .............................................................................................................. ii CHAPTER I: INTRODUCTION ................................................................................................... 1 A. B. C. Background Information on the Arizona Families F.I.R.S.T. Program................... 1 Data Sources Analyzed for the Annual Report...................................................... 3 Organization and Contents of Annual Report........................................................ 4 CHAPTER II: OVERVIEW OF EVALUATION FRAMEWORK.................................................... 5 CHAPTER III: DESCRIPTION OF ARIZONA FAMILIES F.I.R.S.T CLIENTS AND SERVICES RECEIVED ......................................................................................... 8 A. Characteristics of Individuals Referred.................................................................. 8 B. Characteristics of AFF Participating Clients ........................................................ 11 1. Demographic Characteristics................................................................... 12 2. Marital Status........................................................................................... 14 3. Education Level and Employment ........................................................... 15 4. Title XIX Participants ............................................................................... 17 5. Substance Abuse..................................................................................... 18 C. Service Activity .................................................................................................... 21 1. Referrals .................................................................................................. 21 2. Assessments ........................................................................................... 22 3. Levels of Client Engagement in Treatment.............................................. 23 4. Substance Abuse Treatment Services .................................................... 26 5. Time Spent in Treatment ......................................................................... 28 CHAPTER IV: OUTCOMES DATA ........................................................................................... 30 A. Method ................................................................................................................ 30 B. Child Welfare Outcomes among AFF Clients Referred from CPS ...................... 31 1. Research Question 1: Is there a recurrence of child abuse and/or neglect among CPS families participating in AFF? ...................... 31 2. Research Question 2: Are children in foster care whose caregivers enroll in Arizona Families F.I.R.S.T. reunified with their caregivers?............................................................................... 32 C. Employment Outcomes among AFF Participants................................................ 34 1. Research Questions 3 and 4: Do AFF Participants who were employed maintain their employment? Do AFF Participants who were unemployed obtain employment? ........................................... 34 ix D. Summary of Outcomes........................................................................................ 35 CHAPTER V: STATUS OF THE IMPLEMENTATION OF ARIZONA FAMILIES F.I.R.S.T........................................................................................... 36 A. Method ................................................................................................................ 36 B. Perceptions of AFF Program Directors................................................................ 37 1. Contextual Issues and Events ................................................................. 37 2. Clients' Experiences in the Program........................................................ 41 3. Successes, Challenges, and Anticipated Next Steps in the Implementation of AFF................................................................... 46 C. Perceptions of RBHA Representatives................................................................ 51 1. Factors Contributing to the Success of the AFF Program ....................... 51 2. Challenges Encountered and Overcome in Working with AFF................ 52 D. Collaborative Partnerships .................................................................................. 54 CHAPTER VI: CLIENT SATISFACTION .................................................................................... 58 A. B. C. D. E. Clients' Goals ...................................................................................................... 58 Clients' Participatioin in Service Activities ........................................................... 59 Clients' Experience and Satisfaction with AFF .................................................... 60 Clients' Need for Service ..................................................................................... 60 Clients' Knowledge and Understanding of AFF................................................... 61 CHAPTER VII: SUMMARY AND CONCLUSIONS .................................................................... 62 Appendix A: Lessons Learned through the Evaluation Appendix B: AFF Project Director Interview, February 2003 Appendix B: AFF Project Director Interview, June/July 2003 Appendix C: RBHA Representative Interview x 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 8884 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 selfsufficiency through employment. During the second year of the evaluation, the ongoing documentation of program implementation occurred through the analysis and reporting of clientlevel service utilization data and qualitative data gathered from program directors, representatives of Regional Behavioral Health Authorities (RHBAs), and from clients participating in focus groups. Early outcomes in the areas of child welfare and employment also were explored. 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 reenter 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 familycentered, 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 reunification with the child’s birth family. 1 • 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. 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 TERROS Community Partnership of Southern Arizona (CPSA) Arizona Partnership for Children (AZPAC) Old Concho Community Assistance Center AZPAC AZPAC WestCare Arizona Horizon Human Services Southeastern Arizona Behavioral Health Services (SEABHS) County Maricopa Pima Coconino Apache/Navajo Yavapai Yuma La Paz/Mohave Pinal/Gila Cochise, Graham, 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 2 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 2003, ADES extended the AFF provider agencies' contracts to June 2003 in order to coordinate with the fiscal year. Providers' contracts currently are extended to June 30, 2004, and a new solicitation will be required to extend funding beyond that point. Rates have not been increased but additional service units have been amended into some of the providers' contracts due to increased usage of services. Recently, Governor Napolitano released an Action Plan for Reform of Arizona's Child Protection System. In addition to proposing legislation that will amend the definitions of abuse/neglect to clarify that alcohol and drug abuse is a factor that must be considered in determining whether a parent, guardian or custodian has abused and/or neglected an infant or child, agencies are called upon to improve the delivery of alcohol and substance abuse services by replicating the Arizona Families F.I.R.S.T. model. B. Data Sources Analyzed for the Annual Report This annual report draws upon data from multiple sources. Service utilization data are reported for the annual reporting period that covers April 1, 2002 through March 31, 2003. For some of the service activities (i.e., referrals, assessments, levels of engagement) data also are presented from project inception (March 2001) through March 31, 2003. These data on service utilization were obtained from the nine AFF provider agencies and electronically transmitted to the client-level database maintained by the evaluator. In addition, service data obtained through ADHS (for services utilized by Title XIX AFF clients) from the CEDARS and ENCOUNTER data systems, and outcomes data from CHILDS and JAS/AZTEC systems, are included through March 31, 2003. Data on client characteristics were supplied by AFF provider agencies using information available from the assessments completed with clients. To assess perceptions of changes in timeliness, availability and accessibility of services, in-depth interviews were conducted during the first year of the program with AFF program directors and agency administrators. The qualitative findings from these interviews were analyzed and are available in last year’s Annual Evaluation Report (December 2002). To assess changes in program implementation, updates on collaborative partnerships, perceived barriers and facilitators to implementation, contextual issues, and other events that may have influenced service activity, AFF program directors were interviewed by telephone during the winter of 2003 and then again in early summer of 2003. In addition, RBHA representatives were interviewed by telephone during the summer of 2003. Focus groups also were conducted with clients at all sites except at AZPAC Yuma and Horizon, where only one participant showed up at each site and thus an individual interview was conducted. The criteria for inclusion in the focus groups was that clients needed to be currently enrolled in AFF and they needed to be participating in some type of substance abuse treatment service. More detail regarding specific methodologies used has been included in Chapters III, IV, V, and VI where the findings of our analyses are presented. 3 C. Organization and Contents of Semiannual 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 clients referred from project inception through March 31, 2003 are presented. Chapter III also reports on the characteristics of clients participating in services during the annual reporting period of April 1, 2002 through March 31, 2003. Included in the service activity reporting is information on 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). Chapter IV presents available outcomes based on child welfare data extracted from the CHILDS system, and from JAS/AZTEC data, ADHS data, and provider data that addressed employment status of AFF participants. These data enabled the evaluation to assess subsequent CPS reports of abuse and neglect, reunification from foster care, and employment among participating clients as of March 31, 2003. Chapter V presents findings with respect to program implementation. These findings are the result of a systematic qualitative analysis that addressed program directors’ perceptions over time as well as the perceptions of RBHA representatives. Program directors were asked about changes in program implementation and contextual issues affecting the implementation of AFF, as well as their perceptions of facilitators and barriers to client success, the status of collaborative partnerships over the past year, perceptions of clients’ experiences in the program, and lessons learned and important next steps. The RBHA representatives were asked to describe their perceptions of facilitators and barriers to implementing the AFF program, changes in the way the RBHA has been involved in delivering services to AFF clients since program inception, and perceptions of their collaborative partnerships with respective AFF provider agencies. Chapter VI presents findings on client satisfaction based on interviews and focus groups with clients across the AFF provider sites. 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 was designed to address whether the AFF outcome goals and performance measures were achieved as well as other outcomes in the areas of recovery, family stability, safety, permanency, self-sufficiency, and systems change. 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 two annual evaluation reports on AFF (October 2001 and December 2002), an analysis of the policy model was presented. In specific, 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 were analyzed and findings were presented. • 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 two annual evaluation reports, 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. This annual report provides updated information through interviews with project directors regarding any changes to program operations that may have affected service delivery. It also includes the perspective of RBHA representatives with respect to issues affecting service delivery for Title XIX clients in AFF. • 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 sub-component 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 5 manner?), and whether or not there are unmet needs. In prior annual evaluation reports, findings at the operations level from the perspective of CPS, Jobs, and treatment staff, as well as clients, were presented. In the current annual report, the experiences of AFF clients, gathered through new focus groups conducted across AFF sites, are again reported. • 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, referred to as performance measures by the Steering Committee (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). In the December 2002 AFF Annual Evaluation Report, systems level outcomes were presented based on the perceptions of AFF program directors. Participant level outcomes are presented in this annual report for re-allegations of child abuse and neglect, attainment of employment, time in foster care, and reunification from foster care. Completion of treatment and recovery from alcohol and drug problems could not be addressed in this report because the data were not available from providers (this is discussed in detail in Chapter IV). 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, the data presented address the Operations Model and the Program Management Model. 6 Exhibit II-1 Arizona Families F.I.R.S.T. Evaluation Framework Policy Model Program Management Model Operations Model Outcomes Participant Level * Front-Line Staff Issues •Population to be served as defined by legislation •ADES requirements •Coordination of Treatment Fund •Target population •AFF provider agency’s configuration of service delivery system •Planned approach to coordinating services •Staff perceptions & expectations of targeted population •Staff approach to implementing services •Staff perceptions of actual service coordination Participant Issues •Characteristics of AFF • participating clients •Services actually received by participating clients •Client satisfaction with services * Note: The evaluation will report on participant-level outcome findings to the extent that data were made available by the AFF provider agencies 7 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 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 Chapter III DESCRIPTION OF ARIZONA F.I.R.S.T CLIENTS AND SERVICES RECEIVED In this chapter of the annual report, we present available data on the characteristics of individuals referred to Arizona Families F.I.R.S.T. (AFF) between April 1, 2002 and March 31, 2003 and the characteristics of clients enrolled in the program and who received services between April 1, 2002 and March 31, 2003.5 Data are also presented on service activity, including referrals, assessments, service plans, engagement in treatment services, types of treatment services utilized, and length of time that participating clients spent in treatment. Data on all service activities are presented for the 12 month reporting period covered by this report (April 1, 2002 through March 31, 2003). In addition, cumulative data since the inception of the program (March 1, 2001) through March 31, 2003 are presented for client referrals, assessments, and levels of engagement. Findings are summarized using tables, charts and summary bullet points. In the exhibits that follow, most tables include percentages, which 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.” A. Characteristics of Individual Referred In this section, data are presented on characteristics of individuals referred to AFF between March 1, 2001 and March 31, 2003. The information available for 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. 5 Note: In presenting information on clients who received services between April 1, 2002 and March 31, 2003, the clients may have been referred at any time since program inception in March 2001. 8 Exhibit III-1. Age of Individuals Referred: March 1, 2001 – March 31, 2003 (n = 3,927) Provider site AZPAC Coconino AZPAC Yavapai AZPAC Yuma CPSA Horizon Old Concho SEABHS TERROS West Care Under 18 years 3% 1% 2% 1% 1% 1% 1% 1% 1% n=41 1% 18-25 years 33% 25% 32% 27% 32% 20% 28% 30% 28% n=1121 29% 26-33 years 22% 28% 39% 32% 33% 26% 37% 35% 27% n=1296 34-41 years 27% 28% 20% 27% 26% 34% 23% 25% 27% n=1025 42+ years 16% 17% 7% 13% 6% 15% 9% 9% 16% n=420 Missing 0% 2% 0% 0% 1% 4% 1% 0% 1% n=24 n=79 n=187 n=95 n=1044 n=212 n=226 n=135 n=1788 n=161 N=1,148 Total All Sites 33% 26% 11% • Of the clients referred to AFF between March 2001 and March 2003, 29 percent were between 18 and 25 years old; 33 percent were between 26 and 33 years; 26 percent were from 34 to 41 years of age; and 11 percent were 42 years and older. Exhibit III-2. Sex of Individuals Referred: March 1, 2001 – March 31, 2003 (n = 3,927) Provider site AZPAC Coconino AZPAC Yavapai AZPAC Yuma CPSA Horizon Old Concho SEABHS TERROS WestCare All Sites Male 29% 31% 33% 35% 19% 31% 32% 24% 29% n=1105 28% Female 71% 70% 67% 64% 75% 68% 67% 76% 76% n=2,800 Missing 0% 0% 0% 6% 2% 2% 0% 0% n=22 <1% n=79 n=187 n=95 N=212 n=226 n=135 n=1788 n=161 N=3,927 71% Total • 0% n=1044 Of the clients referred to AFF between March 2001 and March 2003, 71 percent were female and 28 percent were male. 9 Exhibit III-3. Race of Individuals Referred: March 1, 2001 – March 31, 2003 (n = 3,927) Race/Ethnicity of Clients Referred by Provider Site 100% 80% 60% 40% 20% 0% e ar tC Asian/Pacific Islander es W Native American /Alaska Native OS RR TE HS AB SE o ch on dC Ol on riz Ho ma Yu Hispanic SA CP i pa va Ya o nin co Co Black C PA AZ C PA AZ C PA AZ White Other Note: Data presented are adjusted for unknown/missing data so column totals are 100%. • Statewide, 63 percent of individuals referred to AFF were White; nine percent were Black; 16 percent were Hispanic, four percent were Native American/Alaskan Native, and three percent were Asian/Pacific Islanders.6 • There was both within-site and cross-site variation regarding the race of clients referred. ¾ Hispanic: AZPAC Yuma reported the highest number of referred clients who were Hispanic (63%). However, due to the low number of referrals at AZPAC Yuma, this site accounted for only 10 percent of Hispanic clients referred Statewide. CPSA reported that 27 percent of their clients referred were Hispanic, accounting for 44 percent of all Hispanic clients referred Statewide. ¾ Black: Fifteen percent of TERROS’ clients referred were Black, which accounted for 75 percent of all Black clients referred across the sites. ¾ White: Sixty three percent of clients referred Statewide were White. Only AZPAC Yuma (29%) reported less than 50% of their clients referred were White. 6 According to 2000 ADES data, the overall racial composition of Arizona's general child welfare population is 49.6 percent White, 3.4 percent Black, 36.1 percent Hispanic, 6.6 percent Native American/Alaskan Native, and 1.6 percent Asian/Pacific Islander. 10 ¾ Native American: Almost 20 percent of clients referred to AZPAC Coconino were Native American (19%), accounting for nine percent of Native American clients referred Statewide. TERROS accounted for more than half (55%) of all Native Americans referred to the AFF program. B. Characteristics of AFF Participating Clients Clients were considered to be participating clients if they had a service plan developed, and were participating in services during the annual reporting period (April 1, 2002 – March 31, 2003). These clients could have been referred to AFF during this annual reporting period or at any time prior to the reporting period. 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 participated in the program. Hence, participation status is indicated when a service plan has been developed. The following data on characteristics of AFF participating clients include those individuals who had a service plan developed (at any point in time) and were receiving services during the annual reporting period (April 1, 2002 – March 31, 2003). 1. Demographic Characteristics The first set of exhibits in this section provide 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 Clients Participating in Treatment between April 1, 2002 - March 31, 2003 (n= 2,417 participating clients) Provider site AZPAC Coconino AZPAC Yavapai AZPAC Yuma CPSA Horizon Old Concho SEABHS TERROS West Care Under 18 years 2% 1% 0% 0% 1% 1% 2% 0% 1% 18-25 years 26-33 years 34-41 years All Sites n=13 1% n=684 25% 21% 20% 24% 33% 23% 34% 30% 30% 28% n=854 27% 29% 46% 35% 34% 32% 37% 36% 35% 35% n=618 33% 33% 24% 29% 23% 31% 18% 24% 22% 26% 42+ years 13% 16% 10% 13% 9% 12% 9% 8% 12% n=245 10% Missing 0% 0% 0% 0% 0% 1% 0% 0% 0% n=3 0% n=52 n=128 n=41 n=481 n=114 n=94 n=107 n=1291 n=109 N=2,417 Total 11 • The patterns with respect to age of participating clients were similar to the ages of individuals referred to the program. Of the clients participating in AFF services between April 1, 2002 and March 31, 2003, 28 percent were between 18 and 25 years old; 35 percent were between 26 and 33 years old; 26 percent were from 34 to 41 years of age; and 10 percent were 42 years and older. Exhibit III-5. Sex of Clients Participating in Treatment between April 1, 2002 - March 31, 2003 (n= 2,417 participating clients) Provider site AZPAC Coconino AZPAC Yavapai AZPAC Yuma CPSA Horizon Old Concho SEABHS TERROS WestCare All Sites Male 21% 27% 27% 34% 18% 29% 33% 22% 24% n=615 25% Female 79% 73% 73% 66% 82% 71% 67% 77% 76% n=1,802 75% Missing 0% 0% 0% 0% 0% 0% 0% 0% 0% n=0 0% N=52 n=128 n=41 n=481 n=114 n=94 n=107 n=1291 n=109 N=2,417 Total • b. Seventy five percent of clients participating between April 1, 2002 and March 31, 2003 were female and 25 percent were male, reflecting a similar pattern to those referred to AFF. Race The exhibit that follows presents information on race of AFF clients participating in treatment between April 1, 2002 and March 31, 2003. 12 Exhibit III-6. Race of Clients Participating in Treatment between April 1, 2002 – March 31, 2003 (n= 2,417 participating clients) Race/Ethnicity of Participating Clients by Provider Site 100% 80% 60% 40% 20% 0% e ar tC Asian/Pacific Islander es W Native American /Alaska Native OS RR TE HS AB SE o ch on dC Ol on riz Ho SA CP Hispanic ma Yu i pa va Ya o nin co Co Black C PA AZ C PA AZ C PA AZ White Other Note: Data presented are adjusted for unknown/missing data so column totals are 100%. • With respect to race/ethnicity of participating clients during the annual reporting period, overall, 67 percent of participants were White; eight percent were Black; 15 percent were Hispanic; four percent were Native American/Alaskan Native; and five percent were Asian/Pacific Islander. • In general, the racial distribution of clients engaged in AFF was similar to the racial distribution of clients referred to the program (e.g., 63% of overall referrals were White, and 67% of overall participants were White; 9% of overall referrals were Black and 8% of overall participants were Black). • There was both within-site and cross-site variation regarding the race of participating clients. ¾ Hispanic: Over one-half of AZPAC Yuma’s participants were Hispanic (59%). However, due to the low number of referrals at AZPAC Yuma, this site accounted for only 10 percent of Hispanic participating clients across the sites. Hispanic clients accounted for only six percent of TERROS’ participating clients between April 1, 2002 and March 31, 2003, but accounted for 16% of Hispanic participating clients cross-site. CPSA accounted for 30% of Hispanic participating clients Statewide. ¾ Black: Thirteen percent of the participating clients served by TERROS were Black, which accounted for 75 percent of all Black participants across sites. ¾ White: More than one-half of the participants at eight of the AFF provider sites were White. Only AZPAC Yuma (37%) reported less than 50% of their 13 participating clients were White. Ninety one 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 six percent of the total number of White clients participating in AFF. ¾ Native American: Almost one-quarter of the participating clients served by AZPAC Coconino were Native American (21%), accounting for nine percent of Native American clients cross-site. TERROS accounted for more than half (58%) of all Native American clients served by the AFF program. 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 April 1, 2002 – March 31, 2003 (n = 2,122 participating families) Number of Children in Participating Families 5or more children 12% 1 child 35% 4 children 11% 3 children 17% 2 children 25% Note: For 341 families, data were missing on the number of children in the family. • Overall, among the 2,122 participating families, there was variation in family size with respect to the number of children in families. • Thirty five percent of participating families had only one child; 65 percent of families had two or more children. • Statewide, 12 percent of families accounted for those with five or more children. 14 Exhibit III-8. Marital Status of Clients Participating in Treatment between April 1, 2002 - March 31, 2003 (n = 2,417 participating clients) Provider Site AZPAC Coconino AZPAC Yavapai AZPAC Yuma CPSA Horizon Old Concho SEABHS TERROS West Care All Sites n=406 Married 31% 27% 20% 18% 22% 21% 27% 14% 9% 17% 12 Consensual 2% 1% 2% 1% 0% 1% 0% 0% 0% 1% 29% 35% 51% 37% 33% 29% 37% 39% 35% 37% 899 Never Married Separated/ Divorced/ Widowed 529 35% 35% 22% 23% 28% 28% 34% 16% 37% 4% 2% 8% 20% 17% 21% 2% 31% 19% 24% n=52 n=128 n=41 n=481 n=114 n=94 n=107 n=1291 n=109 N=2,417 22% n=571 Unknown/ Missing Total 3. • Overall, 17 percent of participating clients were married. • Fifty nine percent of participants were not married. In specific, 37 percent of the participating clients had never been married, and 22 percent of clients across the sites were separated, divorced, or widowed. • Marital status was not known for 24 percent of the participating clients. 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. 15 Exhibit III-9. Highest Education Level Attained by Clients Participating in Treatment between April 1, 2002 and March 31, 2003 (n = 2,417 participating clients) Provider Site Less than High School Diploma/ certificate AZPAC Coconino AZPAC Yavapai AZPAC Yuma CPSA Horizon Old Concho SEABHS TERROS West Care All Sites 33% 37% 32% 37% 37% 34% 43% 14% 38% n=593 24% GED 12% 20% 12% 10% 13% 4% 11% 1% 10% n=132 5% High School Diploma 42% 25% 20% 27% 18% 42% 27% 51% 33% n=980 41% Vocational Education Certificate 6% 5% 0% 7% 8% 0% 1% 0% 0% n=51 2% College Associate Degree 2% 5% 0% 7% 2% 2% 6% 2% 1% n=79 3% College Bachelor Degree 0% 2% 0% 1% 0% 0% 1% 0% 0% n=12 1% College Advanced Degree 0% 1% 0% 1% 0% 0% 0% 1% 0% N=13 1% Unknown 6% 5% 37% 12% 23% 18% 11% 31% 18% n=557 23% n=52 n=128 n=41 n=481 n=114 n=94 n=107 n=1291 n=109 n=2417 Total • Overall, 24 percent of total participating clients across AFF sites did not complete high school. This pattern was consistent across sites, with the exception of TERROS, the largest urban site, where only 14 percent of clients did not complete high school. • For 46 percent of participating clients, a high school diploma or GED was the highest education level attained. • For 23 percent of the participating clients, information was not available on their education level. 16 Exhibit III-10. Employment Status of Clients Participating in Treatment between April 1, 2002 and March 31, 2002 (n = 2,417 participating clients) Provider Site AZPAC Coconino AZPAC Yavapai AZPAC Yuma CPSA Horizon Old Concho SEABHS TERROS West Care Employed Full Time 19% 23% 15% 41% 11% 16% 22% 10% 15% Employed Part Time 13% 10% 10% 11% 4% 12% 12% 4% 6% 0% 0% 0% 2% 0% 0% 0% 2% 0% All Sites n=443 18% n=164 7% n=30 Work Activity1 Educational/ Training Activities2 1% n=28 2% 0% 5% 1% 1% 0% 4% 1% 0% Not Employed 58% 69% 54% 33% 59% 65% 62% 52% 61% Unknown 8% 2% 17% 12% 25% 7% 0% 31% 17% 1% n=1219 50% n=533 Total n=52 n=128 n=41 n=481 n=114 n=94 n=107 n=1291 n=109 1 Work activities include transitional employment, community-based work, facilities-based work activities, sheltered employment. 2 Educational/training activities include education/training, social drop-in/recreational activities, and volunteer activities. 22% N=2,417 • Across AFF sites, 50 percent of clients were not employed; 18 percent of participating clients were employed full-time; and seven percent were employed parttime. • Two percent of clients were involved in a work activity or educational training. • Employment status was unknown for 22 percent of participating clients. • 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 10 percent of the TERROS clients worked full-time. 4. Title XIX Participants Exhibit III-11 presents data on Title XIX status (i.e. enrollment in Medicaid) for AFF participating clients. 17 Exhibit III-11. Title XIX Status of Clients Participating in Treatment between April 1, 2002 - March 31, 2003 (n= 2,417 participating clients) Title XIX Status of Participating Clients by Provider Site 100% 80% 60% 40% 20% 0% e ar tC es W S* O R R TE S* BH A SE o ch on C ld O n* izo or H A* a PS C um Y C A ai ZP ap A av Y C o in PA on AZ oc C C A ZP A Title XIX Clients Non-Title XIX Clients *Title XIX Provider Note: Data presented are adjusted for unknown/missing data so column totals are 100%. 5. • For eight percent of participating clients, Title XIX status (i.e., enrolled in Medicaid) was unknown. After adjusting for unknown/missing data, 82 percent of participating clients Statewide were Title XIX and 18 percent of clients were nonTitle XIX. • All nine AFF provider agencies reported that the majority of their AFF clients, ranging from 63 percent to 85 percent, were Title XIX. Substance Abuse The remaining two exhibits in this section present the reported use of various drugs at AFF enrollment and poly-drug comorbidity patterns among AFF participating clients. Key findings from each of the exhibits are discussed in summary bullets. 18 Exhibit III-12. Types of Drugs Used by Clients Participating in Treatment between April 1, 2002 – March 31, 2003 (n = 2,417 participating clients) Provider Site AZPAC Coconino AZPAC Yavapai AZPAC Yuma CPSA Horizon Old Concho SEABHS TERROS West Care All Sites Alcohol 77% 73% 68% 73% 18% 70% 71% 24% 36% n=1027 Cocaine 17% 27% 24% 63% 10% 16% 24% 12% 0% n=568 24% Marijuana 48% 71% 51% 66% 16% 54% 67% 17% 44% n=861 36% Herion/ Morphine 4% 10% 15% 9% 0% 6% 0% 0% 0% n=105 42% 4% Methamphetamine 33% 73% 68% 30% 56% 47% 50% 11% 72% n=668 28% Total n=52 n=128 N=41 n=481 n=114 n=94 n=107 n=1291 n=109 N=3,229 Note: Percentages do not total to 100% because clients may report use of more than one type of drug. The total (3,229) refers to the total number of drugs reportedly used by clients. • Overall, alcohol was reportedly used by 42 percent of participating clients Statewide at the time of enrollment in AFF. • Marijuana was reportedly used by 36 percent of participating clients. • Methamphetamine use was reported by 28 percent of participating clients. • Cocaine was reportedly used by 24 percent of participants. • Heroin/morphine was reportedly used by four percent of clients. • With respect to site variation, methamphetamine use appeared to be a particular problem in some of the rural areas. In particular, AZPAC Yavapai (used among 73% of participants), WestCare (72% of participants) and AZPAC Yuma (68% of participants). • Six AFF provider agencies (AZPAC Coconino, AZPAC Yavapai, AZPAC Yuma, CPSA, Old Concho, and SEABHS) reported that alcohol was used by 68 percent or more of their participating clients. • Five AFF provider agencies (AZPAC Yavapai, AZPAC Yuma, CPSA, Old Concho, and SEABHS) reported that more than half of their AFF clients used marijuana. The highest rates of marijuana use were reported by CPSA (66%), SEABHS (67%), and AZPAC Yavapai (71%). 19 • Use of cocaine was highest at CPSA, where cocaine was reportedly used by 63 percent of clients. Since CPSA is one of the largest provider sites, it accounts for most of the Statewide cocaine use. Exhibit III-13. Poly-Drug Comorbidity Patterns among Clients Participating in Treatment between April 1, 2002 – March 31, 2003 (n= 1,377 participating clients who reported use of one of the four "frequent drug use categories") Poly-Drug Comorbidity 100% 80% 64% 60% 49% 47%47% 48% 40% 20% 18% 60% 41% 23% 23% 11% 26% 9% 0% Alcohol (n=474) Alcohol Methamphetamine (n=419) Marijuana (n=164) Methamphetamine Marijuana Cocaine (n=320) Cocaine Poly-drug comorbidity 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. • There were 474 participating clients who reported that alcohol was their exclusive or most frequently used substance. Among this group, 49 percent also reported using marijuana. • There were 419 participants who reported that methamphetamine was their most frequently used substance, and among this group, 47 percent also used alcohol and 48 percent also used marijuana. • Among the 164 clients whose most frequently used drug was marijuana, 41 percent also used alcohol, 23 percent also used cocaine, and nine percent also used methamphetamines. 20 • C. There were 320 participating clients who reported that their most frequently used drug was cocaine. Among these clients, 60 percent also used marijuana and 64 percent also used alcohol. Service Activity The information on service activity includes referral and assessment trends over the first two years 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-14 presents data on the number of referrals to AFF since the inception of the program. The data indicate that Statewide the number of referrals was generally constant across the first five quarters, averaging 354 referrals per quarter. Referrals increased in the last two quarters, with double the average number of referrals from the first five quarters (701 referrals) reported between October and December 2002 Exhibit III-14. Number of Referrals by Quarter: Project inception - March 31, 2003 Provider Site AZPAC Coconino AZPAC Yavapai AZPAC Yuma CPSA Horizon Old Concho SEABHS TERROS West Care All Sites