ArizonA FAmiles F.i.r.s.T. ProgrAm Annual Evaluation Report for the period July 1, 2007 — June 30, 2008 College of PubliC ublic Programs This page has been left blank intentionally. ArizonA FAmiles F.i.r.s.T. ProgrAm Annual Evaluation Report for the period July 1, 2007 — June 30, 2008 Prepared for Arizona Department of Economic Security Division of Children, Youth and Families Phoenix, Arizona Contract No.: DES060718 January 2009 Prepared by Center for Applied Behavioral Health Policy School of Social Work College of Public Programs Arizona State University © 2009 by the Arizona Board of Regents for and on behalf of Arizona State University and its Center for Applied Behavioral Health Policy Center for Applied Behavioral Health Policy PO Box 37100, Mail Code 3252 Phoenix, AZ 85069-7100 (602) 942-2247 e-mail: cabhp@asu.edu Web site: http://www.cabhp.asu.edu This document may be copied and transmitted freely. No deletions, additions or alterations of contents are permitted without the expressed, written consent of the Center for Applied Behavioral Health Policy. Acknowledgements This report was prepared by the Center for Applied Behavioral Health Policy (CABHP), Arizona State University, under contract number DES060718-1 with the Arizona Department of Economic Security, Division of Children, Youth and Families (ADES/DCYF), in partnership with the Arizona Department of Health Services, Division of Behavioral Health Services (ADHS/DBHS) through the Joint Substance Abuse Treatment Fund. Brian L. Arthur, Bonnie Carlson, Ph.D. and Michael S. Shafer, Ph.D. are responsible for the content and writing of the report. Appreciation is given to Charles Davis, Linda Crone-Koshel, Ph.D., Manjula Mellachuruvu, Richard Rivera, Matthew Roy, Julie Sauvageot and Myrna Zelaya-Quesada for contributing to the report’s analyses, review, and production. The authors wish to thank staff of the Arizona Department of Economic Security, Division of Children, Youth and Families, and the Arizona Department of Health Services, Division of Behavioral Health Services for their ongoing cooperation and assistance with the evaluation. In particular, Aimee Amado and Carmen Preciado of ADES, and Jennie Lagunas and Steven Lazere of ADHS have been very helpful throughout the course of the evaluation. This report was funded through a contract with the Arizona Department of Economic Security in partnership with the Arizona Department of Health Services, through the Joint Substance Abuse Treatment Fund. Points of view represented in this report are those of the authors, and do not necessarily represent the official position or policies of either the Arizona Department of Economic Security or the Arizona Department of Health Services. Suggested Citation: Center for Applied Behavioral Health Policy. (2008). Arizona Families F.I.R.S.T. Program: Annual Evaluation Report for the Period July 1, 2007 – June 30, 2008. Tempe, AZ: Arizona State University. This page has been left blank intentionally. ArizonA FAmilies F.i.r.s.T. AnnuAl evAluATion rePorT 2008 TABLE of ConTEnTs EXECUTIVE sUMMARY 3 InTRoDUCTIon 9 EVALUATIon fRAMEWoRK 15 CLIEnTs AnD sERVICEs RECEIVED 19 PRoGRAM oUTCoMEs 37 CLIEnT PERsPECTIVEs 45 sUMMARY & ConCLUsIons 53 APPEnDICEs 59 This page has been left blank intentionally. Center for Applied Behavioral Health Policy 3 eXeCuTive summArY Arizona Families F.i.r.s.T. Program model Arizona Families F.I.R.S.T. (Families in Recovery Succeeding Together – AFF) was established as a community substance abuse, prevention and treat­ ment program by ARS 8-881. AFF is a program that provides family-cen­ tered substance abuse and recovery support services to parents or care­ givers whose substance abuse is a significant barrier to maintaining or reunifying the family or achieving self-sufficiency. The program provides an array of structured interventions to reduce or eliminate abuse of and dependence on alcohol and other drugs, and to address other adverse conditions related to substance abuse. Interventions are provided through the Department of Economic Security, Division of Children, Youth and Families (DES/DCYF) contracted community providers in outpatient and residential settings, or through the Regional Behavioral Health Authority (RBHA) provider network under the supervi­ sion of the Department of Health Services, Division of Behavioral Health Services (DBHS). AFF emphasizes face-to-face outreach and engagement at the beginning of treatment, concrete supportive services, transportation, housing, and aftercare services to manage relapse occurrences. The ser­ vice delivery model incorporates essential elements based on family and community needs, such as culturally responsive services, gender-specific treatment, services for children, and motivational enhancement strategies to assist the entire family in its recovery. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 4 The evaluation of AFF, required by ARS 8-884, focuses on the fidelity of program implementation of the AFF model, performance of service pro­ viders, factors that contribute to client success, and the extent to which the legislative outcome goals were met: • Increases in timeliness, availability and accessibility of services • Recovery from alcohol and drug problems • Child safety and reduction of child abuse and neglect • Permanency for children through reunification • Achievement of self-sufficiency through employment This year’s evaluation continued to focus on the documentation of pro­ gram implementation through the analysis and reporting of client-level service data from AFF providers and DBHS, and qualitative data gathered from AFF program directors and AFF clients. Analyses were conducted with respect to child welfare outcomes for the period July 1, 2007 through June 30, 2008. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 5 Key Findings Timeliness, Availability, and Accessibility of services Throughout the state, individuals experiencing difficulties with substance abuse and child abuse and neglect were engaged in treatment services at significant levels. During state fiscal year (SFY) 2008, a total of 5,722 indi­ viduals were served by the AFF program, a 28% increase from SFY 2007, and continuing a steady growth in the number of individuals served. Over 93% of new individuals referred to the program were contacted through outreach and encouraged to seek treatment services – similar to the levels reported in previous years. The AFF providers reduced the amount of time to make initial contact to 1.8 days in SFY 2008 from 2.3 days in SFY 2007, a reduction of one-half day. The process of reaching out to these families and encouraging them to seek help occurs in a rapid fash­ ion, and continues to be one of the cornerstones upon which the program is based. AFF Client Demographic Characteristics The demographic characteristics of AFF clients remain fairly consistent from year-to-year. Among AFF clients in SFY 2008, more than seven out of ten clients (72%) were women, with an average age of 30 years. Persons of Hispanic, African-American, and American Indian heritage comprised 28%, 7%, and 4% of the AFF clients, respectively. Nearly half of the clients (47%) possessed at least a high school diploma or GED (lower than in pre­ vious years), with 31% employed either part- or full-time, somewhat lower than in previous years. Alcohol and substance use Among AFF Clients Based upon the initial assessment information collected on AFF clients, about two-thirds of clients (66%) used alcohol or one or more illegal substances in the 30 days immediately prior to their assessment (based on self-reports). Alcohol (32%), marijuana (31%) and methamphetamine (30%) were the most frequently reported substances used. These findings were consistent with similar findings reported last year. Polysubstance use continues to be the norm, with only 692 clients report­ ing the use of only one substance (16%), 2,999 (68%) reporting the use of two substances, and 709 client (16%) reporting the use of three or more substances. The more common pattern of self-reported multiple sub­ stance use consisted of combinations of alcohol, methamphetamine, and marijuana, similar to that reported last year. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 6 services used By AFF Clients Services data collected from the local AFF contracted providers and matched with information obtained from DBHS suggest that nearly all of the clients enrolled in the AFF program during SFY 2008 received some form of service, with treatment and support services accessed by 91% and 96% respectively of all clients. Slightly more than one-half of clients were provided medical services (primarily laboratory services for drug screen­ ing), with less than one in five clients receiving inpatient, residential treat­ ment, or rehabilitation services. Family (57%), individual (31%) and group (21%) counseling were common treatment services provided to AFF clients in SFY 2008. Screening, evalua­ tion and assessment services were also provided to 89% of AFF clients. Individuals received a variety of secondary therapeutic and support servic­ es. Case management (95%), flex funds (52%), and transportation (31%) were the more commonly reported services. In general, among clients with AFF cases closed in SFY 2008, the average length of treatment was slightly more than six-months (197 days), an in­ crease over the previous year (159 days). Child safety and the reduction of Child Abuse and neglect Children of AFF parents or caregivers were returned to family environ­ ments that were safe and free of abuse or neglect. In SFY 2008, parents who entered the AFF program with a substantiated1 report of child mal­ treatment experienced a recurrence (a subsequent substantiated report) in only 2% of the cases (29 cases), representing less than half the national average of six-month recurrence of 5.4%. Permanency for Children Through reunification Children throughout the state whose parents received AFF program ser­ vices were safely reunited with their parents at rates that exceeded state averages. Over 1,829 children, representing 45% of all children of AFF cli­ ents, achieved permanency this year, up significantly from the SFY 2007 permanency rate of 25%. Among children of AFF clients discharged from DES care, custody and control in SFY 2008, 83% (1,518 children) were safe­ ly reunified with parents or caregivers, with the median length of time in out-of-home placement at 153 days. A substantiated finding is one in which the facts of a report provide a reasonable ground, i.e., some cred­ ible evidence, to believe that abuse or neglect occurred (Arizona Department of Economic security, Division of Children, Youth and families. Children’s services Manual. Retrieved fromwww.azdes.gov/dcyf/cmdps/cps/Policy/ serviceManual.htm on february 3, 2009). 1 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 7 recovery From Alcohol and Drug Problems Statewide, AFF clients were tested on average two times per 30 days of program participation. An important indicator of program effectiveness is the percentage of “clean” or negative UAs indicating no drug use. State­ wide, 90% of UA screenings of closed AFF cases were consistently “clean” (about the same as the past two years), with 68% of those with any UAs reporting all clean tests. Ratios of clean UAs to all UAs varied across providers from a low of .79 to a high of .91. However, the relative rates of self-reported substance use are less impressive and remain unchanged among those clients discharged from the AFF program. At the time of AFF program closure, only 1.5% more clients self-reported that they had used no alcohol or other illicit substance in the past 30 days compared to intake. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 8 ConClusions AnD reCommenDATions During this past year, 5,722 families afflicted by parental substance abuse received services through the Arizona Families FIRST program with 1,518 children safely reunified with their parents or caregivers following treat­ ment. This program, representing a high degree of inter-agency collaboration between DES and DHS, served as a stimulus for Executive Order 2008-01 directing executive branch agencies to take steps that enhance the avail­ ability of substance abuse treatment services for families involved with Child Protective Services. During this past year, enhanced efforts at the detection, referral, and joint processing of substance abusing parents have been initiated and are reflected in the performance indicators of this high­ ly innovative program. Further, this program continues to demonstrate superior performance relative to child safety and permanency planning, enhanced by strategies implemented in accordance with Strengthening Families – A Blueprint for Realigning Arizona’s Child Welfare System. The very nature of this highly innovative program presents its greatest challenge and opportunity. The interplay between two governmental agencies (Department of Economic Security and Department of Health Services) with unique contracting and reporting processes, and the differ­ ences observed in some of the service and outcome data may well be a by-product of blending data obtained from both systems. Three specific areas wherein the interagency nature of this program may be impeding an accurate portrayal of program performance include the following: • Differences in the services reporting requirements of DES and DBHS impede adequate monitoring of the consistency of AFF service provision statewide. DES may want to convene a workgroup with DBHS representatives to examine ways in which DES-contracted treatment services can align with the DBHS Service Matrix. • Past reporting requirements, particularly with regard to substance use and employment, limit the usefulness of the outcome findings from the AFF program. DES may want to examine AFF provider contracts, to ensure that employment status and self-reported substance use patterns are re-assessed at the time of program discharge. • Regional variations in AFF service delivery suggest areas for enhanced program monitoring and technical assistance. DES may want to convene providers and the evaluation team to examine the causes for regional variations in key practice areas. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 9 CHAPTer 1. inTroDuCTion Arizona Families F.I.R.S.T. (Families in Recovery Succeeding Together) was established as a community substance use disorder prevention and treat­ ment program by ARS 8-881 (Senate Bill 1280, which passed in the 2000 legislative session). Under the requirements of the Joint Substance Abuse Treatment fund that was established under the legislation, Section 8-884 requires an annual evaluation of the Arizona Families F.I.R.S.T. (AFF) pro­ gram. The evaluation of AFF examines the implementation and outcomes of community substance use disorder treatment services delivered by AFF-contracted providers and the Regional Behavioral Health Authorities (RBHA) network. Background information on the development of the AFF program is provided in Appendix A. 1.1 Brief Description of the AFF Program and Client Flow The legislation which created AFF is based on the recognition that sub­ stance abuse disorder in families is a major problem contributing to child abuse and neglect, and that substance abuse can present significant bar­ riers for those attempting to reenter the job market or maintain employ­ ment. In addition, federal priorities under the 1997 Adoption and Safe Families Act (ASFA) that address child welfare outcomes (such as perma­ nency and shorter time frames for reunification) coupled with time limits established under the TANF block grant were factors behind the legis­ lation. However, the timeframes for substance abuse recovery currently viewed as a chronic recurring illness2 sometimes conflict with the require­ ments of ASFA and Arizona Juvenile Court guidelines. Currently, states must file a petition to terminate parental rights and concurrently identify, 2 Leshe, A. (2001). Addiction is a brain disease. Issues in science and Technology. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 10 recruit, process, and approve a qualified adoptive family on behalf of any child, regardless of age, that has been in foster care for 15 out of the most recent 22 months. AFF is a program that provides contracted family-centered, strengthsbased, substance abuse treatment and recovery support services to par­ ents or caregivers whose substance abuse is a significant barrier to main­ taining or reunifying the family. The goal of the program is to reduce or eliminate abuse of and dependence on alcohol and other drugs, and to address other adverse conditions related to substance abuse. Interven­ tions are provided through the Department of Economic Security, Division of Children, Youth and Families (DCYF) contracted community providers in outpatient and residential settings or through the RBHA provider network. In addition to traditional services, AFF includes an emphasis on: face-to­ face outreach and engagement at the beginning of treatment; concrete supportive services, such as, transportation and housing; and an aftercare phase to manage relapse occurrences. Essential elements based on fam­ ily and community needs, such as culturally responsive services, genderspecific treatment, services for children, and motivational enhancement strategies to assist the entire family in its recovery, are incorporated into the service delivery. The diagram on the following page shows the flow of clients through vari­ ous stages of the AFF program. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 11 exhibit 1: overview of AFF Program model CPS Case workers Jobs Case workers Referred to AFF Provider Conduct outreach & personal contact with client Engage client in services Current AHCCCS enrolled? No Yes DES/DCYF AFF Network Providers • • • • ADHS/DBHS RBHA Network Providers Continue with AFF provider Conduct core assessment Develop service plan Begin services  Substance abuse education  Outpatient  Intensive outpatient  Residential treatment • • • • • AFF Funded Supportive Services Child care Transportation Housing Job training, etc. Connect to RBHA provider Conduct enrollment Conduct core assessment Develop Service plan Begin services  Covered Services Guide Access AFF Aftercare Services (optional) Close Case Close Case Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 12 Exhibit 2 summarizes the county, AFF provider agency, and associated RBHA within each of six regional DES districts. AFF-contracted agencies in bold italics also participate in the RBHA network as either a RBHA or a RBHA network provider. exhibit 2: list of Des Districts, Counties, AFF Providers, and rBHAs DES District County Regional Behavioral Health Authority AFF Provider Agency I Maricopa TERROS Magellan II Pima Community Partnership of Southern Arizona (CPSA) Community Partnership of Southern Arizona (CPSA) Coconino Arizona Partnership for Children (AzPaC-Coconino) Yavapai Arizona Partnership for Children (AzPaC-Yavapai) Apache and Navajo Old Concho Community Assistance Center Yuma Arizona Partnership for Children (AzPaC-Yuma) La Paz WestCare Arizona Mohave WestCare Arizona Northern Regional Behavioral Health Authority (NARBHA) V Gila and Pinal Horizon Human Services Cenpatico Behavioral Health of Arizona, Inc VI Cochise, Graham, Greenlee, and Santa Cruz Southern Arizona Behavioral Health Services (SEABHS) Community Partnership of Southern Arizona (CPSA) III IV Northern Regional Behavioral Health Authority (NARBHA) Cenpatico Behavioral Health of Arizona, Inc. 1.2 statewide Context of AFF Program and substance use and Treatment In 2007, an estimated 22.3 million persons nationwide (9.0 percent of the U.S. population aged 12 or older) were classified with substance depen­ dence or abuse in the past year based on criteria specified in the Diagnos­ tic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Of these, 3.2 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.7 million were dependent on or abused illicit drugs but not alcohol, and 15.5 million were dependent on or abused alcohol but not illicit drugs.3 The most recent data available on substance use in Arizona4 indicate that 3 substance Abuse and Mental Health services Administration, office of Applied studies (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (nsDUH series H-34, DHHs Pub­ lication no. sMA 08-4343). Rockville, MD. 4 sAMHsA, office of Applied studies. national survey on Drug Abuse and Health, 2004-2006. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 13 10% of Arizonans were classified with alcohol or illicit drug dependence or abuse in the past year, slightly higher than the national average. Sev­ enteen percent of Arizonans 18-25 years of age and 6% of Arizonans 26 years of age or older used illicit drugs during the past month. Further, past-month binge alcohol abuse was reported by 41% and 21% of indi­ viduals within these two age groups respectively. Finally, in a recent report on substance use in the 15 largest metropoli­ tan areas,5 8% of persons living in the Phoenix metropolitan area aged 12 or older reported using any illicit drug in the past month, and 25% of persons living within the Phoenix metropolitan area reported past-month binge alcohol use, significantly higher than the national average. Abuse and neglect of children is generally believed to be associated with substance abuse. In reports to Congress on this issue,6,7 data was pre­ sented showing that parents who abuse drugs and alcohol generally do not attend to children’s emotional cues, are poor role models, and dis­ cipline their children less effectively than other parents. It is within this context that the AFF program is meant to intervene and break the cycle of substance abuse, and the abuse and neglect of children. As noted by Breshears, Yeh and Young,8 leading researchers and advocates in the child welfare system: “An effective partnership between the child welfare and alcohol and drug treatment systems can help parents with substance abuse issues retain or gain a parental role with their child, while not putting the child at risk of harm.” (page 1) In September 2005, the Arizona Department of Economic Security, Divi­ sion of Children, Youth and Families (DCYF) released Strengthening Fami­ lies – A Blueprint for Realigning Arizona’s Child Welfare System. The Blue­ print identifies five key objectives to be achieved by Summer 2006: • Develop safe alternatives that result in fewer children placed in out-of-home care; • Reduce the number of children in congregate care settings; • Serve children ages birth to six years in their homes, kinship care or foster care without using group homes; sAMHsA, office of Applied studies (2007). The NSDUH Report. U.s. Department of Health and Human services (1999). Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection. Washington, DC: Us Depart­ ment of Health and Human services. 7 U.s. General Accounting office (1994). Foster Care: Parental Drug Abuse Has Alarming Impact on Young Children. GAo/HEHs-94-89. 8 Breshears, E., Yeh, s., & Young, n. (2004). Understanding substance Abuse and facilitating Recovery: A Guide for Child Welfare Workers. U.s. Department of Health and Human services, substance Abuse and Mental Health services Administration. Rockville, MD. 5 6 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 14 • Stop the placement of children ages birth to three years in shelter placements; and • Reduce the length of stay of children in shelters to no more than 21 days. The SFY 2007 annual report for DES9 linked the objectives of the Blueprint with the accomplishments of DCYF in decreasing the number of children in out-of-home care by 158 children, or 1.6 percent and reducing the num­ ber of children placed in congregate care. Other results included: • The number of children in settings such as group homes and shelters decreased by 100 children, or almost 7%; • The number of children six years old or younger in group homes decreased by 22%; • The number of children three years old or younger in shelters decreased by 18%; and • The number of children placed in family-like settings remained relatively stable at 78% in SFY 2007. The following chapters summarize the findings of the AFF program evalu­ ation for the period ending June 30, 2008: Chapter Two describes the methodology and data sources used for the AFF annual evaluation and enhancements to the evaluation design. Chapter Three summarizes AFF client characteristics, process measures, and services. Chapter Four highlights child welfare outcomes, such as preventing maltreatment recurrence, timely reunification, maintaining permanency upon leaving care, as well as, decrease use of alcohol and illegal drugs. Chapter Five discusses the annual findings and presents recommenda­ tions for program enhancements. 9 Arizona Department of Economic security. The Arizona Department of Economic Security’s Annual Report for the period July 1, 2006 through June 30, 2007. (2008). Phoenix, AZ. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 15 CHAPTer 2. evAluATion FrAmeWorK AnD DATA sourCes The evaluation design developed for the AFF program focuses on pro­ gram implementation to determine whether AFF provider agencies im­ plemented the service model as intended by the legislation and program administrators. The design also addresses whether the AFF outcome goals and performance measures, as well as other outcomes in the areas of sub­ stance abuse recovery, family stability, safety, permanency, self-sufficiency, and systems change, were in fact achieved. The evaluation design is not a longitudinal study of AFF clients using data collected from individual cli­ ent interviews, nor does it use any comparison group. Rather, the design uses primarily administrative data covering points in time. This year’s report draws upon data from multiple sources. Four core prin­ ciples guided the use of data sources for the AFF program evaluation: • Minimize the data collection burden to a level that satisfactorily meets the legislatively mandated evaluation requirements; • Avoid duplicative data collection efforts; • Use existing administrative data and formats whenever possible; and • Respect the differing management information systems capabilities among the nine AFF providers. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 16 Data sets included: • Service utilization data obtained directly from the nine AFF providers; • Enrollment and encounter data provided by the Arizona Department of Health Services, Division of Behavioral Health Services (DBHS) for services provided through the local RBHA network; • DES CHILDS information system, which provides child welfare information, and the DES JAS/AZTEC information system, providing employment services information; and • Qualitative information obtained from AFF program managers and clients. Comments or findings from program managers and clients are provided throughout the report in “text box” format. These comments are from a qualitative report on site visits conducted in May and June of 2008 and provided to the AFF program office. Site visit reports are available from the Center for Applied Behavioral Health Policy at Arizona State University. AFF providers use a common data reporting format, revised by the AFF evaluation contractor, for the reporting period beginning July 1, 2007. The primary information used for the analysis of AFF program services is ser­ vice utilization data obtained directly from the nine AFF providers. These data were collected by the AFF providers and sent to the evaluation team in a variety of electronic formats and imported into a client-level database developed and maintained by the evaluation contractor. Service utiliza­ tion data are reported for the annual reporting period that covers July 1, 2007 through June 30, 2008. For some service activities, data are also presented from program inception (March 2001) through June 30, 2008. Another data set used for the analysis of the AFF program was enrollment and encounter data provided by DBHS for services utilized by Title XIX AFF clients. DBHS service utilization data are reported for the annual reporting period that covers July 1, 2007 through June 30, 2008. It should be noted that DBHS service utilization data is constantly updated and added to by the RBHAs and their providers; there may be a reporting lag from service delivery to appearance in the DBHS information system of anywhere from 30 to 90 days. The service utilization data for Title XIX AFF clients is mod­ erately complete through June 30, 2008, since DBHS provided the data set in early September 2008. Three additional data sets used for this evaluation include: the ADES CHILDS information system which provides child welfare information; the ADES JAS/AZTEC information system providing employment services in­ Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 17 formation; and data from the Temporary Assistance for Needy Families (TANF) information systems. These data are reported for the annual re­ porting period that covers July 1, 2007 through June 30, 2008. The third major source of data used for the analysis of the AFF program is AFF stakeholders. These stakeholders include AFF program managers, staff, and clients of the program. A variety of data collection methodolo­ gies were used with these stakeholders, including individual interviews, focus groups, and satisfaction surveys. The purpose for using this third data source was to document and assess programmatic successes, changes in program implementation, updates on collaborative partnerships, per­ ceived barriers and facilitators to program implementation, changes in contextual issues, and other events that may have positively influenced service delivery. The evaluation framework guiding this year’s evaluation report is provid­ ed in Appendix B. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report This page has been left blank intentionally. Center for Applied Behavioral Health Policy 19 CHAPTer 3. AFF ClienTs AnD serviCes reCeiveD During the SFY 2008 reporting period, a total of 5,722 individuals were served by the Arizona Families FIRST program, representing a 28% in­ crease over the previous year (4,471 clients), This figure includes clients who were referred, assessed, and received treatment in SFY 2008 (n = 4,000), along with clients who were referred and assessed in SFY2007 and continued to receive services in SFY 2008 (n = 1,722). Exhibit 3 (on the fol­ lowing page) presents a visual depiction of the flow of clients into the AFF program during the current reporting period. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 20 exhibit 3: sFY 2008 referrals and Client Participation Unique Individuals Referred to AFF n = 4,691 Referral Outreach n = 4,365 Individuals Accepting Services n = 3,639 Individuals Assessed n = 4,381 3,012 new referrals + 1,369 referred in SFY 2007* but assessed in SFY 2008 + SFY 2008 New AFF Clients n = 4,000 SFY 2007 Continuing AFF Clients* n = 1,722 Total AFF Clients, SFY 2008 N = 5,722 AFF Funded Clients 1,279 clients received treatment services funded from AFF only 794 clients closed from services 485 clients continuing to receive services Shared Funding Clients 1,804 clients received treatment services funded from both AFF & RBHA 444 clients closed in both systems 683 clients closed by AFF, continuing to receive services from RBHA 66 clients closed by RBHA, continuing to receive services from AFF 611 clients continuing to receive services from both systems RBHA Funded Clients 2,639 clients received treatment services funded from RBHA only 1,285 clients closed from services 1,354 clients continuing to receive services * Many of the individuals assessed in 2008 but referred to Aff in 2007 were clients of the DBHs/RBHA system; similarly, many of the continuing Aff clients were individuals receiving services through the DBHs/RBHA system. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 21 3.1 referrals to the AFF Program A total of 4,800 referrals (representing 4,691 unduplicated individuals10) were received by AFF providers during SFY 2008, averaging 1,200 referrals per quarter. Nearly all referrals to the AFF program (97%) were provided by CPS caseworkers, a trend that has been consistent since the inception of the program. Only 10 referrals came from the Jobs program during the reporting period ending June 30, 2008. There were 131 referrals for which the referral source was unspecified by the AFF provider. Referrals in DES District I constituted over half of all referrals (57%), followed by DES District II (23%) and District III (9%) as shown in Exhibit 4. Since the incep ­ tion of the AFF program in 2001, more than 26,400 individuals have been referred to the program. exhibit 4: AFF Program referrals (Total referrals and unique referrals) by Provider and Quarter DES District I II AFF Provider TERROS CPSA AzPaCCoconino AzPaCYavapai Old Concho AzPaCYuma 690 625 674 736 2725 308 243 304 257 1112 21 7 27 15 70 61 33 59 54 207 56 37 42 48 183 56.8% 23.2% 1.5% 4.3% 2641 1098 70 205 Jul-Sep 2007 Oct – Dec 2007 Jan – Mar 2008 Apr – Jun 2008 Total Referrals % of Total Referrals Unique Clients III IV V VI Westcare Horizon SEABHS Statewide Averages15 21 13 22 16 72 48 21 46 32 147 25 43 50 36 154 30 25 36 39 130 1260 1047 1260 1233 4800 3.8% 1.5% 3.1% 3.2% 2.7% 100.0% 182 72 147 154 122 4691 3.2 Client outreach and engagement Among the 4,691individuals that were referred to the AFF program in SFY 2008, 93% received at least one or more recorded outreach attempts by the AFF provider within their community. AFF providers made these initial outreach attempts in a timely manner, averaging just 1.8 days in SFY2008, compared to 2.3 days in SFY 2007. Four of the nine AFF providers (CPSA, AzPaC-Coconino, Horizon & SEABHS) did not meet the AFF contract speci­ fications regarding outreach rates, falling slightly below the threshold that 90% of all referrals results in outreach services. Among those individuals provided outreach, the rate of service engage­ ment remained high again this year, averaging 77.6% of all clients receiv­ ing outreach. The rates of service engagement varied across the districts, with a high of 100% in District IV – Westcare, to a low of 27% in District II – CPSA. This year’s low rate within District II represents sharp decline from last year’s acceptance rate for this district (65%) and warrants further Each referral is valid for a six-month period. If an individual does not engage in services within six months of the initial referral, a new referral is sent to the Aff provider. 10 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 22 attention and scrutiny by DES program staff to understand the reasons for this year’s decline. exhibit 5: Disposition of Cases referred to the AFF Program* *In some cases (n=130), Aff providers recorded the client accepting Aff referral services without indicating any information on outreach efforts. This data entry inconsistency will be addressed with Aff providers in sfY 2009. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 23 exhibit 6: Disposition of Cases referred to the AFF Program* Westcare Horizon SEABHS VI AzPaC-Yuma V Old Concho IV AzPaCYavapai III AzPaCCoconino AFF Provider II CPSA I TERROS DES District Statewide Averages # unduplicated referrals* 2641 1098 70 205 182 72 147 154 122 4691 # outreached 2542 946 61 195 174 66 145 135 101 4365 % outreached 96.3% 86.2% 87.1% 95.1% 95.6% 97.1% 98.6% 87.7% 82.8% 93.1% Avg. days referral to outreach (standard deviation) 2.1 (11.2)** 1.4 (3.8) 0.7 (1.4) 1.6 (5.3) 0.2 (1.4) 2.6 (4.9) 0.8 (1.5) 0.5 (1.5) 0.8 (1.5) 1.8 (9.0) # of referred clients accepting services*** 2518 298 51 171 174 69 147 147 64 3639 % of referred clients accepting services 95.3% 27.1% 72.9% 83.4% 95.6% 95.8% 100% 95.5% 52.5% 77.6% # referred to RBHA 0**** 393 2 94 165 17 121 35 9 836 % of referrals sent to RBHA 0% 35.8% 2.9% 45.9% 90.7% 23.6% 82.3% 22.7% .4% 17.8% 0 1 10 14 20 1 1 1 1 49 # of referred clients refusing services * The term “referrals” is defined as the receipt of an Aff referral form from DEs by an Aff provider. The referral identifies the name of an individual referred for Aff services. ** The larger standard deviation for TERRos indicates that there is more variability in days from referral to outreach than a provider whose standard deviation is smaller; the larger standard deviation for TERRos may be the result of outliers which are not typical of the rest of the data, or may be data entry errors. *** The term “accepting referral” is defined as a referred individual indicating their willingness to accept Aff services upon outreach by an Aff provider. **** since TERRos is both an Aff provider and a contracted provider to the RBHA, operationally their practice has been not to report Title XIX clients as “referred to RBHA”. This does present some inconsistency in the manner in which Aff providers account for Title XIX clients during the referral process. This issue will be addressed by the Evaluation Team in sfY 2009. Additional outreach details by AFF provider are summarized in Appendix C. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 24 3.3 AFF Provider Assessments and DBHs enrollments A total of 4,38111 individuals (representing 93% of all individuals referred to the AFF program) received assessment and evaluation services12 dur­ ing SFY 2008. Assessments were conducted by a contracted AFF provider and/or a DBHS/RBHA contracted provider, depending on the referred indi­ vidual’s eligibility status for Title XIX Medicaid funding. Assessment data were compiled from two sources: AFF provider data and DBHS enrollment data. Of the 4,381 assessment/ enrollment records, 46% of individuals as­ sessed have records from both an AFF assessment and a DBHS enrollment, 28% were unique assessments supplied by AFF providers, and 26% were unique assessments reported from DBHS enrollment data. The ratio of assessments conducted to referrals received in state fiscal year 2008 is higher than in previous years due to increased efforts to track individuals referred to the RBHA system. A summary of key performance indicators associated with the assessments from providers within each of the DES districts is shown in Exhibit 7. eXHiBiT 7: 2008 Assessments by Des District DES District Total Assessments RBHA only AFF & RBHA AFF only I II III IV V VI Statewide 2419 993 420 215 162 172 561 (23.19%) 922 (38.11%) 768 (77.34%) 62 (6.24%) 302 (71.90%) 69 (16.42%) 181 (84.18%) 8 (3.72%) 95 (58.64%) 36 (22.22%) 96 (55.81%) 57 (33.13%) 936 (38.69%) 163 (16.41%) 49 (11.66%) 26 (12.09%) 31 (19.13%) 19 (11.04%) 4381 2003 1154 1224 3.4 Characteristics of AFF Clients During the SFY 2008 reporting period, a total of 5,722 individuals state­ wide were AFF clients. More than half (52%) of all AFF clients were located in District I, while Districts II and III accounted for an additional 24% and 10% respectively of all AFF clients. Seventy percent of AFF clients were enrolled during the current reporting period and considered new clients, while the remainder (30%) were enrolled during the preceding year(s) and continued to receive services during the current reporting period. Exhibit 11 provides a comparison by district of new and continuing clients. note: This figure includes individuals that had been referred to the Aff program in sfY 2007, but not assessed until sfY 2008, along with clients who were referred and assessed during sfY 2008. 12 The term “assessed” is defined as individuals having completed the DBHs initial “Core Assessment.” 11 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 25 DES Districts I and III had the higher percentage of new clients (74% and 68%) respectively, while District V had the lowest percentage of new cli­ ents (55%). The demographic profile of AFF clients has remained relatively consistent from year to year. Key findings of the demographic profile of AFF clients include: • Approximately seven out of 10 (72%) of AFF clients were women. • The average age of an AFF client was 30 years, consistent with previous reports. • Twenty-eight percent of all AFF clients were of Hispanic or Latino(a) descent. • Seven percent of AFF clients were African Americans, and 4% were American Indian, consistent with last year’s report. • Marital status is reported on 56% of AFF clients; of these clients over half were reported as single, never married. • Nearly half of AFF clients (47%) had at least a high school diploma or GED, somewhat lower than last year (51%). • 31% were employed either full or part time, somewhat lower than last year (39%). Additional details about AFF client characteristics by DES district are sum­ marized in Appendix D. 3.5 substance use Among Clients at Time of AFF Assessment or rBHA enrollment AFF clients’ use of alcohol and illicit substances is assessed at intake through a self-report; no physiological assessment is currently required at intake. As such, substance use patterns at intake should be interpreted with cau­ tion. Exhibit 8 provides a summary of the substances used by AFF clients at the time of their initial assessment. Based on the initial assessment in­ formation collected on 5,722 AFF clients, about two-thirds of individuals (66%) reported they had used alcohol or one or more illicit substances in the 30 days immediately prior to their assessment. Alcohol (32%), mari­ juana (31%), and methamphetamine (30%) continue to be the more com­ monly reported substances. Polysubstance use continues to be the norm, with only 692 clients reporting the use of only one substance (16%), 2,999 (68%) reporting the use of two substances, 709 (16%) reporting the use of three or more substances. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 26 Appendix E provides detailed information on self-report­ eXHiBiT 8: substances used by AFF ed substance use patterns by DES District. These data Clients 30 Days Prior to enrollment continue to document the elevated rates of metham­ phetamine use, particularly among new clients located in Mohave, Pinal, Yavapai, and Yuma counties with rates Total Clients: 5,722 of methamphetamine use between 40% and 45% of AFF # % clients reporting use in the 30 days prior to their assess­ ment. Cocaine/crack use was higher in Pima County (31%) Clients Reporting Use 3,765 65.8% compared to other counties. 3.6 service use by AFF Clients Alcohol 1853 32.4% Benzodiazepines 63 1.1% Cocaine/crack 776 13.6% Services data are collected from the local AFF contracted 55 1.0% Hallucinogens provider and matched with service data obtained from 142 2.5% Heroin/Morphine DBHS allowing for an integrated analysis of all services 15 0.3% Inhalants provided to these parents during the course of their for­ mal involvement in the AFF program. Due to the challeng­ 1752 30.6% Marijuana es of integrating services information from these various 1737 30.4% Methamphetamine sources, service taxonomy was created for the AFF pro­ 126 2.2% Other drugs gram (see Appendix F). This services taxonomy consists of 177 3.1% Other Narcotics eight broad service domains subdivided into 34 discrete types of services, referred to as service subtypes. The ser­ 39 0.7% Other sedatives vices taxonomy represents a combination of service levels 26 Other Stimulants 0.5% that are uniquely identified by one state agency or the other but not both, along with ser­ vices that are identified and shared in eXHiBiT 9: Polysubstance use Among AFF Clients common by both state agencies. The Among AFF Clients whose variation in the types and amounts of Clients also used... Primary Substance Use is... services provided to AFF clients rep­ resents differences in the actual mix 44% also use Marijuana Alcohol 35% also use Methamphetamine of services from one AFF provider to (n = 1853) 39% also use other illegal substances another, as well as variations in the contractual relationships between lo­ 46% also use alcohol Marijuana 41% also use methamphetamine cal AFF providers and the area RBHA. (n=1752) 34% also use other illegal substances Information regarding services is pre­ 41% also use marijuana Methamphetamine sented from three vantage points. 37% also use alcohol (n= 1737) First, analyses of service access among 32% also use other illegal substances AFF clients are presented. These anal­ yses focus on the proportion of AFF clients who were reported to have at least one service encounter (a pro­ vider billing claim) recorded for the provision of service and answer the question, “How many clients accessed what sorts of services?” The second analysis focuses on service dosage and seeks to answer the question, “How much service did clients receive?” Due to the limitations of these services data, we are limited to counting the number of encounters (provider bill- Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 27 ing claims) as an estimate of the amount of services that clients received.13 These service data do not currently allow for an accurate estimate of the true amount of time or units of service that clients received, but simply the number of discrete billings that a provider submitted for payment of the service. The final analyses of services data that will be presented will seek to answer the question, “How are these services funded?” or “Which state agency is paying for what services?” As will be shown, the AFF pro­ gram continues to demonstrate a shared commitment with both DES and DBHS (through Title XIX Medicaid funding) sharing the fiscal responsibil­ ity of meeting client needs. 3.7 service Access by service Domain As the data in the accompanying table reflect, nearly all clients that were served in the AFF program during the past year received services within treatment domain (91%) and the support domain (96%). Treatment servic­ es include, for example, counseling (individual, group and family) and out­ patient services. Support services encompass such things as case manage­ ment and transportation assistance. Approximately two-thirds of clients (65%) received services within the medical domain, while 20% or fewer of all AFF clients received services within the Rehabilitation, Crisis Interven­ tion, Inpatient, Residential, or Behavioral Health Day Program domains (see Appendix G). DBHs encounter claims include information such as: procedure code, start date, end date, and number of units claimed. Each procedure code description contains a billing unit that describes the amount of time for that pro­ cedure, i.e., code 90804, individual psychotherapy, approximately 20 to 30 minutes face-to-face with the patient. Aff claims typically bill for a service in weekly increments, such as intensive outpatient services defined as a minimum of nine (9) hours per week, or one (1) week of supportive services. 13 eXHiBiT 10: service Access, Domain level, statewide (n = 5,722) Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 28 Closer examination of the level of service access at the domain level reveals minor variations in service access across the six DES districts. As indicated by the following chart, the relative rates of clients that accessed treatment and support services were fairly stable across the state, with 80% or more clients in all six districts receiving at least one unit of service within each of these service domains. Slight variations in service access across the DES dis­ tricts are noted. District I reported lower rates of access to rehabilitation services, whereas medication service access was lower in Districts II and IV, while Districts II and V demonstrated elevated rates of access to crisis ser­ vices. Rates of residential, inpatient, and behavioral health day program participation were consistently low across all districts with 10% or less of clients receiving services within these domains. eXHiBiT 11: service Access, Domain, by District DES Districts I II III IV V VI Statewide Participating Clients 3001 1354 573 311 224 259 5722 Services Treatment Services Rehabilitation Services Medical Services Support Services Crisis Intervention Services Inpatient Services Residential Services Behavioral Health Day Prgms # % # % # % # % # % # % # % 2840 94.6% 1160 85.7% 517 90.2% 279 89.7% 188 83.9% 219 84.6% 5203 90.9% 400 13.3% 310 22.9% 181 31.6% 87 28.0% 62 27.7% 96 37.1% 1136 19.9% 2313 77.1% 558 41.2% 362 63.2% 237 76.2% 100 44.6% 164 63.3% 3734 65.3% 2951 98.3% 1236 91.3% 558 97.4% 303 97.4% 216 96.4% 252 97.3% 5516 96.4% 283 9.4% 310 22.9% 35 6.1% 18 5.8% 17 7.6% 47 18.1% 710 12.4% 23 0.8% 23 1.7% 31 5.4% 8 2.6% 2 0.9% 13 5.0% 100 1.7% 170 5.7% 203 15.0% 48 8.4% 12 3.9% 23 10.3% 22 8.5% 478 8.4% 270 9.0% 47 3.5% 21 3.7% 1 0.3% 2 0.9% 0 0.0% 341 6.0% Comparison of the rates of service dosage, expressed as the median num­ ber of encounters recorded for a client within a service domain revealed common patterns across the state in some service domains with other pat­ terns specific to particular DES Districts. As reflected in the chart below, the service domains of support and residential services tended to show the highest rates of service encounters among those clients who accessed services within these domains. Crisis and rehabilitation service domains tended to demonstrate the lowest rates of encounters. Relative patterns of service dosage varied across the six DES districts, although DES District II demonstrated significantly lower rates of encounters in three primary domains (support, residential, behavioral health day programs) relative to other DES districts. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 29 eXHiBiT 12: median service encounters Per Client Within a service Domain by Des District DES Districts I II III IV V VI Statewide Participating Clients 3001 1354 573 311 224 259 5722 Services Treatment Services 8 5 6 6 8 9 7 Rehabilitation Services 1 2 5 4 2 3 2 Medical Services 4 7 9 11 5 8 5 Support Services 23 6 13 19 13 15 16 Crisis Intervention Services 1 1 1 1 1 1 1 Inpatient Services 3 3 4 3 5 2 3 Residential Services 2 5 22 18 29 22 13 Behavioral Health Day Prgms 12 3 11 8 12 0 11 3.8 service Access and service encounters by service level Turning to the discrete service levels provided to clients, a series of charts are presented that indicate the level of service access within each service domain, segmented by DES district, and the level of service dosage within each service domain, again segmented by DES District. These data provide graphical evidence of the variations in the relative rates with which AFF clients access services throughout the state, and the relative rates of the amounts of service (estimated by the median number of service encoun­ ters) that these clients are afforded (see Appendix H). Treatment Services. The treatment services domain is composed of sev­ en service levels, which include assessment and evaluation, three forms of counseling, two levels of outpatient programming, and other treatment services. Statewide assessment and evaluation services were the most commonly accessed service, received by 60% (District V) to 90% (District I) of all clients. The most common type of counseling received was family (57%), followed by individual (31%) and group (21%). With the exception of District I, individual and group counseling were the treatment services accessed by the fewest proportions of clients. While more than 50% and 30% of AFF clients in District l received group and individual counseling, respectively, fewer than 10% of clients in all other districts were reported to have received these services. All other treatment services were accessed by relatively few clients, with the exception of other treatment services in District II (14%) and outpatient treatment services in Districts I and VI (greater than 20% in both districts). While assessment and evaluation was the most commonly accessed service within the treatment services do­ main, it was provided for the briefest amount of time, as clients across all districts were recorded with a median of two encounters for this service. “Other” treatment services was the category of service most frequently provided to clients, averaging a median of nine encounters per client statewide, ranging from a low of five encounters in District II to highs of Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 30 28 (District III) and 29 (District V). Clients received relatively low doses of counseling services, with median rates of encounters across the state at six encounters for family counseling, one encounter for individual counseling, and seven for group counseling. With the exception of District IV, which reported a median of 15 encounters, clients received very little individual counseling, averaging two encounters or less. eXHiBiT 13: Percent of Clients with at least one Treatment service encounter and median service encounters per Client by Des District DES Districts Participating Clients Treatment Services Family Counseling Individual Counseling Group Counseling Assessment, Eval., Screening Other Treatment Services Intensive Outpatient Outpatient I 3001 % Median 49.9% 52.5% 35.6% 91.5% 5.6% 5.4% 22.2% 5 1 7 2 17 3 4 II 1354 % Median 48.3% 0.7% 0.3% 67.2% 14.2% 0.1% 10.4% 7 1 1 2 5 3 1 III 573 % Median 58.6% 1.6% 3.8% 75.0% 4.2% 6.1% 6.1% 7 1 5 2 28 4 3 IV 311 % Median 58.2% 0.6% 8.4% 76.8% 3.9% 9.3% 5 15 7 2 18 11 V 224 % Median 67.9% 5.8% 2.2% 63.4% 9.8% 10.7% 7 2 2 2 29 4 VI 259 % Median 58.7% 1.2% 71.8% 8.9% 5.8% 27.4% 12 1 2 14 2 6 Statewide 5722 % Median 52.7% 28.6% 20.0% 82.5% 7.8% 3.8% 17.1% 6 1 7 2 9 3 4 Rehabilitation Services. The Rehabilitation Services Domain is com­ prised of three service levels: psycho-educational services, skill develop­ ment and training, and behavioral health promotion and prevention. With the exception of clients receiving skills development and training in DES District VI, these services were accessed by 15% or fewer of all clients statewide. The number of encounters recorded for clients accessing reha­ bilitation services, with few exceptions, averaged across all three service levels and across all six DES districts, at 2 or less. Districts II and III demon­ strated slightly elevated rates of skill training and development, District IV slightly elevated rates of behavioral health prevention and promotion, while Districts III, IV, and V showed elevated rates of psycho-educational services. eXHiBiT 14: Percent of Clients with at least one rehabilitation service encounter and median service encounters per Client by Des District DES Districts Participating Clients Rehabilitation Services Skills Training & Development I 3001 % Median 6.5% 2 II 1354 % Median 12.6% 3 III 573 % Median 16.9% 4 IV 311 % Median 10.9% 2 V 224 % Median 15.6% 2 VI 259 % Median 32.8% 2 Statewide 5722 % Median 10.9% 3 Behavioral Health Prevention/ Promotion Education 6.4% 1 1.5% 1 7.7% 1 15.1% 3 1.8% 1 3.5% 1 5.6% 1 Psychoeducational Sevices 3.5% 2 13.7% 2 16.4% 7 11.9% 6 19.2% 3 10.8% 2 8.7% 2 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 31 Medical Services. This service domain consists of four service sub-types: medication, laboratory services, medical management services, and phar­ macy services. As depicted in the following graphs, the rates of laboratory service access varied widely from nearly 70% in District I to a low of 15% in District II. Medical management and pharmacy services were accessed by 10-30% of clients across all DES districts, while medication services were ac­ cessed by very few clients. These few clients however, reported the high­ est levels of encounters in Districts II (205 median encounters) and V (208). In contrast, laboratory, medication management, and pharmacy services were all reported at relatively modest rates of 10 or fewer encounters across all districts. eXHiBiT 15: Percent of Clients with at least one medical service encounter and median service encounters per Client by Des District DES Districts Participating Clients Medical Services Medication Services I 3001 % Median 2.6% 142 II 1354 % Median 2.4% 205 % 0.3% III 573 Median 10 Laboratory Services 70.0% 3 17.7% 5 44.2% 8 68.2% 9 28.6% 3 41.7% 7 52.8% 4 Medical Mgt Services Pharmacy Services 17.4% 19.6% 3 6 28.1% 28.2% 2 6 33.0% 28.3% 2 6 22.8% 18.0% 3 6 20.1% 19.2% 2 7 30.5% 30.5% 2 6 22.8% 23.2% 3 6 % 1.0% IV 311 Median 73 % 0.9% V 224 Median 208 % ­ VI 259 Median ­ Statewide 5722 % Median 2.1% 142 Support Services. The Support Services Domain is comprised of 12 ser­ vice levels, ranging from case management to child care and including flex funds (non-medically necessary covered services), supported housing, self-help/peer support services, and personal care services. As reflected in the accompanying figures, case management is the most commonly reported service accessed by clients, with greater than 90% of all clients reported to have accessed this service. All other service levels within the Support Services Domain pale in comparison to case management, with flex funds and transportation being the two more commonly accessed services at 52% and 30% of clients statewide, respectively. Self-help and peer support services were accessed by 30-37% of the clients in Districts V and VI, with all service levels within this domain accessed by 15% or fewer of the clients in all districts. While case management was the most com­ eXHiBiT 16: Percent of Clients with at least one support service encounter and median service encounters per Client by Des District DES Districts Participating Clients Support Services Case Management Personal Care Services Home Care Training/ Family Support Self-Help/Peer Services Unskilled Respite Care Supported Housing Sign Language/ Interpretive Flex Fund Services Transportation Child Care After Care Other I 3001 % Median 96.3% 22 0.8% 2 1.1% 1 11.6% 2 ­ ­ 1.3% 31 0.1% 1 60.0% 1 33.7% 6 ­ ­ 2.6% 1 11.4% 2 II 1354 % Median 78.7% 7 1.3% 29 2.7% 1 13.1% 1 0.4% 1 1.9% 9 0.9% 4 44.5% 1 14.5% 2 0.9% 1 0.4% 3 III 573 % Median 95.6% 11 1.4% 2 2.3% 2 6.5% 2 7.7% 5 0.2% 1 40.0% 1 35.6% 7 0.2% 1 7.3% 1 19.2% 4 IV 311 Median % 93.2% 9 2.3% 2 5.1% 4 9.0% 3 ­ 1.6% 17 0.3% 1 39.9% 1 25.1% 6 1.3% 3 11.9% 5 49.8% 9 V 224 % Median 92.4% 9 2.2% 2 1.8% 20 29.9% 3 6.3% 2 28.6% 1 46.9% 10 0.9% 1 VI 259 % Median 95.8% 11 3.5% 2 5.0% 2 36.7% 3 1.9% 28 4.2% 7 34.4% 1 36.3% 8 2.7% 1 26.3% 3 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Statewide 5722 % Median 93.1% 15 1.3% 3 2.1% 1 13.3% 2 0.4% 2 2.1% 11 0.5% 2 51.6% 1 30.0% 5 0.1% 2 3.1% 1 12.1% 3 College of Public Programs, Arizona state Univeristy 32 monly accessed service, it was also provided at the most consistent levels, with clients statewide averaging a median of 15 encounters for this ser­ vice. Supported housing, while provided to very few clients, was provided at relatively intense levels within District I (40 clients with a median 31 en­ counters), District IV (5 clients, 17 encounters), and District VI (5 clients, 28 encounters). With two exceptions (personal care services in District II and home care training in District V), all other service levels within the Support Services Domain were provided at rather modest levels. Crisis, Inpatient, Residential, and Behavioral Health Day Treat­ ment. Across these four service domains, a total of eight service subtypes are nested. Due to their relative low rates of both access and dosage, these four domains have been combined for this report. With few excep­ tions (most notably in the area of crisis stabilization services in District II) all of the services comprising these four service domains were accessed by a minority of clients, generally at rates below 5%. Among those clients that did access these services, short term residential treatment services predominated in the number of encounters, averaging a median of 20 encounters per client in all districts, with the exception of District II where the median per-client encounter for this service was 5. Within District I, two (2) clients were recorded as accessing residential treatment with their children present; for these two clients, the median number of encounters was 25. eXHiBiT 17: Percent of Clients with at least one Crisis, inpatient, residential, BH Day service encounter and median service encounters per Client by Des District DES Districts Participating Clients Crisis, Inpatient, Residential & Behav. Health Day Services Crisis Mobile Crisis Stablization Inpatient Services Short Term Residential Level II Long Term Residential Level III Child Residential w/Parent Supervised Behavioral Health Treatment and Day Therapeutic Behavioral Health Treatment and Day I 3001 % 4.2% 6.9% 0.8% 5.7% ­ 0.1% II 1354 Median 1 1 3 20 ­ 26 % 2.2% 21.7% 1.7% 15.0% - III 573 Median 1 1 3 5 - % 4.5% 1.7% 5.2% 8.0% - IV 311 Median 1 1 4 22 - % 4.8% 1.0% 2.6% 3.5% 0.3% - V 224 Median 1 1 3 22 1 ­ % 5.8% 1.8% 0.9% 9.8% 0.4% - VI 259 Median 2 1 5 29 3 - % 8.9% 10.4% 5.0% 8.5% - Statewide 5722 Median % 1 4.1% 1 9.7% 2 1.8% 22 8.4% <0.1% <0.1% Median 1 1 3 13 2 26 0.5% 6 ­ ­ ­ ­ ­ ­ ­ ­ ­ ­ 0.3% 6 8.6% 12 3.5% 3 3.7% 11 0.3% 8 0.9% 13 ­ ­ 5.8% 11 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 33 3.9 service mix by Fund sources One of the historic hallmarks of the AFF program has been the high de­ gree of collaboration between DES and DBHS. As noted previously, the network of local contracted AFF providers in some communities repre­ sents a mix of local agencies that have concurrent contracts with the DBHS RBHA and DES (Regions I, II, V, & VI), while in other communities the local AFF provider is contracted with DES, but not with the DBHS RBHA (Districts III & IV). Providers in this latter group attempt to work collaboratively with their local RBHA to facilitate referral and enrollment into the Title XIX Medicaid program for those clients meeting appropriate eligibility criteria. This mix of local service providers has afforded opportunities for DES and DBHS to create complimentary funding streams to ensure equitable access to services throughout the state. Examination of the agency source from which services are funded for clients illustrates this blending of funding streams. The accompanying table identifies the primary agency fund source used by AFF providers to support the provision of services. As this table illus­ trates, most services identified at the service level, or actually funded by one state agency fund source or another, but typically not both. Seven of the identified service levels were found to be funded by both agencies, while nine service levels were primarily funded by DES with the remaining balance of 15 services funded primarily by DBHS. Those services funded jointly by DES and DBHS include those services accessed by the majority of AFF clients, including case management, screening and assessment, and pharmacy services. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 34 eXHiBiT 18: Primary Funding source Primary Fund Source (> 80% of encounters paid by fund source) DES only DES & DBHS DBHS only Treatment Services Family Counseling Individual Counseling Group Counseling Assessment, Evaluation, Screening Other Treatment Services Intensive Outpatient Outpatient X X X X X X X Rehabilitation Services Skills Training & Development BH Prevention./Promotion Education Psycho-educational Services/Employment Support X X X Medical Services Medication Services Laboratory Medical Management. Pharmacy X X X X Support Services Case Management Personal Care Services Home Care Training/Family Support Self-Help/Peer Support Unskilled Respite Care Supported Housing Sign Language/Oral Interpretive Services Flex Fund Services Transportation Child Care After Care Other X X X X X X X X X X X X Crisis Intervention Services Crisis Mobile Crisis Stabilization X X Inpatient Services Residential Services Short-Term Residential Level II Long-Term Residential Level III Child Residential w/Parent X X X Behavioral Health Day Programs Supervised BH Treatment & Day Programs Therapeutic BH Services & Day Programs Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report X X Center for Applied Behavioral Health Policy 35 3.10 service Closure and service Duration During SFY 2008, 2,523 clients (representing 44% of all clients served) cas­ es were closed by both the RBHA and DES during the reporting period. An additional 43% of all clients served in SFY 2008 were still open at the end of the reporting period, while 13% (n=749) of all clients were closed in one but not both of the systems. The overwhelming majority of the par­ tially closed had been closed by the AFF provider, while remaining open and accessing services from the RBHA. eXHiBiT 19: summary of AFF Case Closures AFF Clients 5,722 100% Closed AFF Cases 2,523 44% Partially Closed AFF Cases 749 13% AFF Cases Closed By RBHA Open in AFF 66 1% Open AFF Cases 2,450 43% AFF Cases Closed by AFF Open in RBHA 683 12% Length of stay (LOS) is computed by counting the number of calendar days from the date of a client assessment to the date of case closure. LOS has become an increasingly important indicator of treatment success and correlates with long term sobriety.14 In general, among those AFF clients whose cases were closed in SFY 2008, those clients who had received ser­ vices from the RBHAs experienced longer LOS than clients served by AFF providers. Comparing clients served exclusively in one system or the other, we observed that RBHA only served clients had a mean length of stay of 273 days, compared to a mean length of stay of 160 days for those client served exclusively by an AFF provider. For those clients served by both systems, LOS15 continued to favor RBHA based services. Clients served by both systems and closed by both systems had a mean LOS of 240 days; clients served in both systems and closed by the RBHA (but not AFF) had a United nations-office on Drugs and Crime. (2002). Contemporary Drug Abuse Treatment: A Review of the Evidence Base (Electronic Version) Retrieved from www.unodc.org/pdf/report_2002-11-30_1.pdf 15 Los for dually enrolled clients calculated as the days from client assessment to the date of closure within the system filing the closure. 14 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 36 mean length of stay of 219 days; clients served in both systems and closed by the AFF provider (but not by the RBHA had the shortest length of stay at 137 days. As such, these data suggest that among those AFF clients re­ ceiving services, clients that accessed services from a RBHA provider expe­ rienced longer periods of service provision than clients accessing services from non-RBHA affiliated AFF providers. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 37 CHAPTer 4. AFF ProgrAm ouTComes This chapter highlights the outcomes experienced by families that have participated in the AFF program. Outcome information is presented on the following key dimensions articulated in the enabling legislation es­ tablishing the AFF program: child safety, family stability and permanency, self-sufficiency as reflected in employment, and recovery from alcohol and drug problems. 4.1 Child safety: recurrence of Child maltreatment Of the total of 5,722 clients in the AFF program, 4,882 (85%) had at least one report of suspected child maltreatment prior to entering AFF while the remaining 840 (15%) had no reports of suspected child maltreatment prior to entering the AFF program.16 Among the 4,822 clients with a report at intake, 1,228 (22%) clients had reports that had been substantiated,17 3,570 (62%) clients had reports that were unsubstantiated, while 84 (2%) clients had reports whose status was proposed as substantiated pending review by the Department’s due process proceedings. Following their enrollment in the AFF program, subsequent reports of child maltreatment were reported against 1,290 clients, representing just 22.5% of all clients served in SFY 2008. Among these clients with a child maltreatment reporting filing subsequent to their enrollment in At the time this report was prepare, it was unclear how individuals would be referred to the Aff program with­ out a prior CPs report or Jobs Program referral. This finding will be investigated further by the evaluation team in the october-December 2008 quarterly evaluation report. 17 A substantiated finding is one in which the facts of a report provide a reasonable ground, i.e., some credible evidence, to believe that abuse or neglect occurred (Arizona Department of Economic security, Division of Chil­ dren, Youth and families. Children’s services Manual. Retrieved from www.azdes.gov/dcyf/cmdps /cps/Policy/ serviceManual.htm on february 3, 2009). 16 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 38 AFF were 362 parents who had not had a report at the pre-assessment period. Among those parents with reports prior to and subsequent to their enrollment in AFF, less than 10% of the recurrent reports were sub­ stantiated. Thus, the percentage of substantiated cases dropped from 22% of all cases prior to AFF program enrollment to 11% after AFF pro­ gram enrollment. These findings are depicted in Exhibit 25. The rates of report substantiation varied significantly by DES District, from a low of 9% in District I to a high of 25% in District II. The National Child Abuse and Neglect Data System (NCANDS) indicates that for 2006 (the most recent year that data are available) 9% of all Arizona maltreatment reports were substantiated compared to a national substantiation average of 25%.18 Integrating these data suggests that the state overall displays a rate of substantiation that is far below the national average, with District II ap­ proximating the national average. During the reporting period, 84% of substantiated cases consisted of ne­ glect, 12% were physical abuse, and 3% sexual abuse. One child of AFF parents died as a result of the maltreatment reported at pre-assessment. Similarly, last year the vast majority of substantiated maltreatment cases were also for neglect (94%), and the remainder (6%) for physical or sexual abuse. These findings are consistent with other studies that showed sub­ stance abusing caregivers tend to be linked with neglect referrals rather than with sexual or physical abuse referrals.19 eXHiBiT 20: statewide Pre-Assessment and Post-Assessment Child maltreatment reports Pre-Assessment Substantiated Finding Totals # % 1228 22% Post Assessment Finding Substantiated # % 29 13.8% Unsubstantiated # % 137 14.4% Finding Pending # % 19 15.0% No Report # % 1043 23.5% Unsubstantiated 3570 62% 79 37.6% 561 58.9% 91 71.7% 2839 64.1% Finding Pending 84 2% 0 0 8 0.8% 4 3.1% 72 1.6% No Report 840 15% 102 48.6% 247 25.9% 13 10.2% 478 10.8% Total 5722 100% 210 100.0% 953 100% 127 100% 4432 100% Exhibit 25 also provides information on child maltreatment recurrence statewide. Of the 4,882 families with a report at pre-assessment, at postassessment, 928 or 19% had a recurrence. Using the more conservative definition of recurrence used by NCANDS (subsequent substantiated re­ ports following an initial substantiated report, a recurrence rate of 2.4% in AFF program participants was obtained. For informational purposes, the federal standard for absence of maltreatment recurrence within six months is 94.6% (allowing, therefore, recurrence of 5.4%). Thus, for U.s. Department of Health and Human services, Administration on Children, Youth and families. Child Mal­ treatment 2006 (Washington, D.C.: U.s. Government Printing office, 2008). 19 sun, A., shillington, A.M., Hohman, M., & Jones, L. (2001). Caregiver AoD Use, Case substantiation, and AoD Treatment: studies Based on Two southwestern Counties. Child Welfare, 80(2), 151-177. 18 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 39 SFY2008 among AFF families, recurrence was lower (better) than this na­ tional standard.20 4.2 Permanency Achieved by Children of Parents in AFF A total of 4035 children whose parents were AFF clients in SFY 2008 were in CPS care at some point during the reporting period. As depicted in Ex­ hibit 26, 54% (2175) of these children were still in out of home placements at the end of the reporting period.21 By comparison, in SFY2007, 75% of children of parents in AFF were still in care at year’s end. For comparison purposes, nationally, in 2005 71% of children reunified with parents were eXHiBiT 21: Permanency Achieved by Children of Parents in AFF Other 1% Still in Care 54% Reunification 38% Permanency 45% Guardianship 4% Relatives 2% Adoption 1% reunified in less than 12 months.22 Just under half of the total number of children in care at any point during the year (1829, 45%) achieved per­ manency during SFY2008. Of those who were discharged from care and achieved permanency (n=1829), the vast majority (83%) were reunified with their families. Others found permanent homes with relatives (n=73, 4%), through adoption (n=37, 2%), emancipation (n=26, 1%) or guard­ ianship (n=179, 10%). Rates of reunification varied across the six districts, from a low of 75% in District IV to a high of 92% in District V. For com­ parison purposes, 80% of the children of AFF parents who left the care of DES in SFY2008 were reunified with parents or caregivers. The average 20 U.s. Department of Health and Human services, Administration on Children, Youth and families. Child Mal­ treatment 2006 (Washington, D.C.: U.s. Government Printing office, 2008). 21 Included in this group are children who are participating in trial visits with relatives, guardians, or potential adoptive families. 22 U.s. Department of Health and Human services, Administration on Children, Youth and families. Child Wel­ fare Outcomes 2002-2005 . (Washington, D.C.: U.s. Government Printing office, 2008). Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 40 number of days in care during SFV2008 was 241 eXHiBiT 22: Days in out of Home Placement (SD=257), varying from a low of 204 days in District for Children Who Achieved Permanency I to a high of 307 in District V. (N=1829) Median Among the children who achieved permanency 23 (see Exhibit 27), the median number of days in Relatives (n=73) 4 out-of-home care for children subsequently living Reunification (n=1514) 153 with relatives was 4 days, followed by 153 days for Guardianship (n=179) 421 children reunified with birth families, 421 days for Adoption (n=37) 721 children where guardianship was arranged, and 721 for children who were adopted. It should be noted that the median number of days in care for reunified children in District I (89 days) was significantly lower than the statewide median of 241. Additional details on days in care by DES District are summarized in Appendix I. 4.3 recovery from substance Abuse Reductions in substance abuse can be evaluated from two sources of in­ formation: self-reports and urinalysis (UA).24 With the former, compari­ sons are made between the responses obtained at intake and at discharge from the AFF program among those clients for whom a useable intake and termination/discharge screening are available. Comparison of the number of UAs collected that detect continued substance use (positive UA) to the number of UAs collected that detect no substance use can be used as an alternative measure of recovery from substance abuse. Unfor­ tunately, both of these measures only provide an assessment of substance use during the time of AFF program participation. Currently, no data are collected that assess continued abstinence following program completion (e.g., 6 month, 12-month follow-up). Urinalysis. Usable urinalysis results were available for just half (n = 1242, 49%) of AFF clients, approximately the same percentage (53%) as last year. As such, slightly more than one-half of all program participants, either were not assessed with urinalysis, or, the results of these urinalysis were not reported. An important indicator of program effectiveness is the per­ centage of “clean” or negative UAs indicating no drug use. Statewide, 90% of UA screenings of closed cases were consistently “clean” (about the same as the past two years), with 68% of those with any UAs reporting all clean tests. Ratios of clean UAs to all UAs varied across providers from a low of .79 to a high of .91. Statewide, 13% of UAs tested positive for drugs, with similar variability across sites in the percentage of “dirty” UAs reported, with a high of 61% at CPSA and a low of 0% in Yuma. One way to examine the effectiveness of the AFF program is to look at The mid-point wherein half the children spent less time in care and half spent more time in care. Information provided by Aff providers does not allow for a determination of the substances that were assessed by the urinalysis. 23 24 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Average 17 215 391 791 Center for Applied Behavioral Health Policy 41 the extent to which a child maltreatment report was received during the program period in relation to the ratio of “clean” UAs to the number of UAs performed. Statewide, the ratio was .90, indicating that 90% of cli­ ents’ UAs were negative for drugs. There was not a significant difference in the ratio of clean UAs between groups of parents with no maltreatment report, compared to those with a substantiated or unsubstantiated mal­ treatment report eXHiBiT 23: Average Drug screens per Client by Des District and AFF Provider Westcare Horizon SEABHS VI AzPaC-Yuma V Old Concho IV AzPaCYavapai III AzPaC Coconino AFF Provider II CPSA I TERROS DES District Statewide Averages Number of Participants 3001 1354 84 310 179 105 206 224 259 5722 Mean 2.94 1.24 13.76 20.50 2.83 6.87 15.86 2.96 13.20 4.65 Std. Dev. 4.30 3.93 22.94 28.32 6.00 7.76 15.17 6.75 44.64 13.92 eXHiBiT 24: Average Frequency of uAs per month by District DES District Median I II III IV V VI Statewide Averages 0.79 0.67 1.62 1.84 0.25 1.02 0.87 Mean 1.32 1.81 3.64 2.95 0.8 7.6 2.09 Std Dev 2.09 4.67 8.15 4.84 1.38 42.14 10.43 Statewide, across all clients and providers, AFF clients received an average of 5 drug screenings in SFY2008. There was substantial variability across sites, as shown in Exhibit 28, as clients in some programs (Horizon, CPSA, TERROS) were tested on average, three times or less, while other providers (AzPaC, SEABHS, Westcare), 10 times or more, during the course of their treatment. Providers are required by contract to conduct urinalysis on program par­ ticipants on average, twice per month. As reflected in summarized in Exhibit 29, the statewide average frequency of UAs among those clients who had UAs reported was two per 30 days; meeting the specified re­ quirement. Providers in Districts III, IV, & VI reported 30-days rates of UAs that met or exceed the state standard while providers in Districts I, II, and V reported 30-day rates of UA testing that fell short of the state standard. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 42 Self-Report. Exhibit 30 provides a comparison of the response patterns among 1,629 AFF participants who were closed in SFY 2008 and for whom a useable pre-assessment and post-assessment of self-reported substance abuse self-report was available. As the data in this table indicate, among the 351 individuals that were recorded as reporting using methamphet­ amine in the 30 days immediately prior to their enrollment in the AFF program, nearly 90% (86.3%) were recorded as also reporting such use at program discharge. This pattern is quite consistent; the overwhelm­ ing majority (80% or more) of participants’ self-reported substance use remains the same at discharge as that record at intake. The consistency of this patterns leads to some suspicions that the finding might be spurious, an artifact of inaccurate or lapsed reporting as opposed to no reduction in substance use. This suspicion strengthens as we look at the results of the urinalysis data. eXHiBiT 25: self-reported substance use at Time of Closure Post Assessment PreAssessment # % 585 35.90% 259 15.90% 144 8.80% 228 14.00% # 525 17 3 22 % 89.70% 6.60% 2.10% 9.60% # 17 230 1 1 % 2.90% 88.80% 0.70% 0.40% 21.50% 37 10.50% 3 0.90% 1 0.30% 6 3.80% 100% 6 610 9.70% 37.40% 4 256 6.50% 15.70% 0 152 0.00% 9.30% 3 224 None Alcohol Cocaine/Crack Marijuana/Hashish Methamphetamine/ 351 Speed All others 62 Totals 1629 None Alcohol Cocaine/ Crack # % 11 1.90% 2 0.80% 138 95.80% 0 0.00% Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Cannabis/ Hashish # % 11 1.90% 3 1.20% 1 0.70% 200 87.70% Meth All Others # 16 7 0 5 % 2.70% 2.70% 0.00% 2.20% # 5 0 1 0 % 0.90% 0.00% 0.70% 0.00% 1.70% 303 86.30% 1 0.30% 4.80% 13.80% 0 331 0.00% 20.30% 49 56 79.00% 3.40% Center for Applied Behavioral Health Policy 43 4.4 Child Permanency in relation to substance use Patterns Exhibit 31 depicts the relationship between parental self-reported sub­ stance use in the 30 days before discharge and child status. A somewhat higher percentage of children whose parents did not report substance use achieved permanency (78% versus 71% of those reporting substance use). Looking just at cases where children were reunified with families (83% of those who achieved permanency), there were no differences according to whether parents reported drug use (81%) or did not report use in past 30 days (83%). eXHiBiT 26: Child outcome status According to Parent substance use status Parental Self-Reported Substance Use at Discharge Child Status Still in care Achieved permanency N % N % Used in past 30 days (n=1551) 458 29 1098 71 Did not use (n=2103) 473 22 1630 78 4.5 Parental employment Employment status is collected at program enrollment and at discharge. Employment status rates at intake and at discharge were compared for a group of 1,635 clients with an intake and a discharge assessment. As depicted in Exhibit 32, 26% of program participants were employed at intake; at discharge, the rate of employment had increased to 31%. Like­ wise, while 60% reported they were unemployed at intake, the rate of unemployment drops slightly at discharge to 59%. Generally, the employ­ ment status reported at intake is the same status reported at discharge. eXHiBiT 27: employment status at enrollment and Discharge Pre Employment Status Totals # % Employed 430 26.3% Unemployed 987 60.4% Other 218 13.3% Totals 1635 100% Employed # % 394 91.6% 82 8.3% 25 11.5% 501 30.6% Post Employment Status Unemployed # % 30 7.0% 886 89.8% 57 26.1% 973 59.5% Other # 6 19 136 161 % 1.4% 1.9% 62.4% 9.8% Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report This page has been left blank intentionally. Center for Applied Behavioral Health Policy 45 CHAPTer 5. ClienT PersPeCTives AFF providers are urged to develop a continuum of services that is fam­ ily centered, child focused, comprehensive, coordinated, flexible, commu­ nity based, accessible and culturally responsive. This section of the report summarizes information from AFF site visits with clients and AFF program managers. First, we provide a summary of client satisfaction that speaks to the provision of services responsive to clients’ needs and cultural, de­ mographic and geographic diversity. Secondly we end this chapter with a summary of similar and contrasting viewpoints of AFF services during the past year based on interviews with AFF program managers. 5.1 summary of Annual AFF Client Focus groups Client Characteristics and services Seventy-eight AFF clients participated in focus groups and were asked about the services received as well as the timeliness and satisfaction with those services. Seven out of ten focus group participants were female (71%) and most were Caucasian (62%). About three out of ten participants (29%) were of Hispanic/Latino descent, 7% American Indian, and 2% were African-American. Client participation ranged from six to 12 clients in nine different focus groups. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 46 Program services When clients were asked about AFF program services, clients in all areas mentioned substance abuse education and counseling, and clients in six of the nine areas cited assistance with basic needs such as food boxes. Trans­ portation assistance was mentioned by clients in six of the nine groups. Other frequently mentioned services included: housing, clothing, individ­ ual counseling and/or emotional support, and financial support for one­ time needs. Similar to last year, most clients reported receiving services in a timely manner and felt they were receiving the services that they needed. A sam­ pling of client comments include the following. “When I didn’t show for my appointment, they were at my door. There were times when I was home, but I wouldn’t open the door. I would stand there real quiet so they wouldn’t think I was home. They just kept coming back. There is a lot of devotion there.” “When I came into the AFF program four years ago, it took two months. This time, I called AFF last week and I started today. My son just moved in with me again. I’ve been in residential care for several months.” “I was enrolled quickly, but not long after I ended up in jail. They (AFF) didn’t visit me when I was in jail, but as soon as I was out, the visits started up again immediately. I wish they would continue classes and visits in jail. I feel like I lost a lot of time not getting their services while I was in jail.” “Everything has been real quick. We were able to get clothing and diapers within the first week.” “They were able to get me into a parenting class right away.” “I had to move from one city to another; CPS didn’t refer me to AFF in Flagstaff. I called the AFF office crying and they got me in right away.” “I get help to pay for my medications. I really appreciate that. I couldn’t afford them on my own.” “Everyone here is anxious to get you what you need—the counselors and the AFF case managers. I requested marriage and family therapy and I got it right away.” “My AFF worker went to court with me; he/she waited with me in the court house until my hearing. That made a huge difference to me.” “They treat you like a person. They aren’t judgmental. They get to know you.” “They (AFF) are always there when you need them.” There were also expressions of frustration with agencies and systems in the delivery of service. “I had to wait about a month and a half to get AHCCCS.” “It took two weeks for my CPS referral to AFF; two weeks from AFF to the RBHA; and two weeks from the RBHA to substance abuse classes. That’s six weeks, so no, my process was not fast.” Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 47 “They want you to be here for hours before and after your assessment appointment. I couldn’t stay—I had a doctor’s appointment, so I ended up having to reschedule and waiting again.” satisfaction with Program AFF clients participating in the focus groups expressed satisfaction with the program. The prevailing sentiment expressed by focus group partici­ pants was that the AFF program provided them with emotional support of having “someone on your side” as expressed in these comments. “They are very helpful. They are good with the CPS case workers. They are just good people. They gave me moral support, emotional support. They made anything they could available to me. They speak up for me at meetings.” “My self-esteem was nothing. Now I feel good about myself. It’s the best thing that’s ever happened to me.” “It’s easier to get jobs. I always had to take jobs where I didn’t get tested. Now I don’t have to worry about that. I can apply for any job I want.” “Providing random UAs has helped me a lot. It helped to keep me honest in the beginning; now it helps to keep CPS honest.” “It keeps me believing that I can fight CPS to get my son back. AFF totally backs me up.” “I did the treatment plan. I didn’t want to do it at first. I found out a lot of things that I probably should have learned but I didn’t. It will help me with future relationships. I like the homework. It is really good. I wish we had more homework.” “I’ve been in this program a couple of times. The first time was four years ago. I came in with my husband. I just came back to the program today. I was happy to come back to AFF. They gave me chances when I didn’t deserve them.” “They (AFF) have helped us with everything; rent, bills. They went to court with me. They are always available to talk to.” “They got me into IOP classes. They helped me to get regular visitation with my son. I was able to get into parenting classes.” “My relationship with my kids is much better. They are adjusting better because now I am having more regular visitation with them.” “I think I’m ready this time. I’ve been through this process three times, but I wasn’t ready—I didn’t work at it. Now I know that I can’t fail again. That’s it.” “My kids will be returning home next month. I don’t think that would be possible without this program.” “I think this program will make me ready for court. I want to make sure I do everything I need to do to get my kids back. My AFF worker keeps good records—he/she writes a report for court.” “I know I can’t do this alone. This program has taught me that it’s okay to need help. I can ask for help now.” Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 48 “I started in this program in December. I received substance abuse classes and parenting classes. I was in a substance abuse treatment group here for six months. I completed the program. I finished getting my GED, and I’m going to college in August. I live in the Horizons PEART II house—it’s a threebedroom house. I pay $300 a month for it. Housing was the only thing that was holding me back from getting my kids. I’m going to start working as a Peer Support worker soon. We are getting our own place in July.” 5.2 summary of Annual AFF Coordinator interviews outreach and engagement Common barriers to successful client outreach and engagement men­ tioned by AFF coordinators across sites included: • Clients changing phone service or having no phone • Client reluctance or ambivalence • Inaccurate referral information • Frequent relocation of clients and/or homelessness • Substance abuse relapse from time of CPS referral to initial outreach or contact • Difficulty in reaching clients in remote locations • Higher gas prices impacting clients Specific strategies that some providers have developed during the past year to overcome these barriers included • Within District I (TERROS), outreach staff are now going out and making contact with existing clients in order to encourage their continued engagement with services. In addition, TERROS received a subcontract from DES to augment AFF services through the addition of Peer Recovery Coaches who help in the outreach and engagement process. • Within District II (CPSA) the AFF Coordinator provides continuing, monthly education to CPS workers. Through these monthly meetings CPS workers help the provider in making and maintaining client contact as demonstrated by the comment “Sometimes CPS alerts us to next court date which helps us to make contact with homeless clients.” Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 49 • The SEABHS (District VI) Coordinator stated that “We have 85 vehicles at our disposal to assist us in providing [transportation] services to clients in the communities where they live.” • In order to reduce delays due to inaccurate referral information, the AFF Coordinator at AzPaC-Flagstaff (District III) reported that “We verify contact information immediately. We identify other services clients may be involved in and use them as a point of contact.” • The AFF program in AzPaC-Prescott (District III) received their CPS referrals via secure email: “This is an easier way to track referrals. We also have a process in place for unsuccessful visits: if the client is not there, the worker calls the CPS worker for further instruction.” Completion of Client Assessments Barriers to the successful completion or delays in the completion of client assessments included the following issues: • Clients have scheduling conflicts or poor time management skills. • There was too few staff in some locations across districts to meet the needs of clients. • Clients have improper or no identification, which causes a delay in the provisions of services. • Clients have low motivation or are in a precontemplation stage of change for treatment services. • In some situations, one parent is engaged in services and the other is not. • One AFF Coordinator reported that in some instances “clients’ attorneys tell clients to not talk about their case,” meaning the client won’t sign an initial release. • Another AFF Coordinator reported that “some of the Behavioral Health Centers we work with won’t provide us with client information even if the client has signed a release. We’ve worked on building relationships with these centers, but this is an ongoing problem with some Centers.” • An AFF coordinator stated that “Our RBHA contacts clients for appointments on the last Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 50 day of our assessment deadline,” rather than sooner within the contracted timeframe. Specific strategies that some providers have developed during the past year to overcome these assessment barriers included: • One site Coordinator stated that “We’ve assigned a clinical liaison who completes assessments.” • Other coordinators reported that “We go to the CPS office with the client and we provide evening sessions and childcare.,,” or “…we schedule the RBHA appointment while the client is in the office and provide a planner to the client that has the appointment written in it…” • As a final example of overcoming assessment barriers, a northern Arizona provider stated that “We have a bilingual case manager who translates during the assessment process….” Also, in an effort to reduce the number of “no-shows” at the time of the assessment appointments, AFF staff enter into a written agreement with clients that they [the client] will attend the assessment session: “There are consequences for client for no-shows. We notify the CPS worker. We just don’t have enough slots available, and the noshow appointments eat a lot of my staff’s time.” substance Abuse Treatment services Barriers to the successful client engagement in treatment services across districts included: • There is a delay or waitlist for available residential treatment beds/services; a lack of public transportation, especially in rural areas; unstable client lifestyles such as unemployment or homelessness; and substance use relapse. • In addition, some coordinators reported that CPS places increasing restrictions or requirements upon clients which often discourages them. AFF clients are often confronted with conflicting treatment priorities with various providers and/or agencies. An increasing barrier to treatment is service availability for nonEnglish speaking clients and clients who are illiterate. • Specific strategies that some providers have developed during the past year to overcome Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 51 these assessment barriers included: • Across all districts, the Meet Me Where I Am (MMWIA) Campaign through the Department of Health Services, Division of Behavioral Health Services is having a positive impact on eligible families. This program expands the amount and quality of support and rehabilitation services available to Child and Family Teams for the express purpose of helping children live successfully in their own communities. • Some District I AFF clients will have the added benefit of Peer Recovery Coaches, which will assist in engaging and supporting clients during their treatment process. • Another AFF provider promotes a proactive approach in maintaining client engagement in services by informing clients that they are welcome in the program at any time; “We don’t punish clients for missing groups; we provide make-up sessions for missed groups. If they do drop out, we make sure they understand that the door is always open.” • Other solutions include programming for women’s groups, groups for couples, and a domestic violence prevention and education group. • A provider in District III reported that a residential treatment center is available to clients who are Spanish-speaking; also, there is residential treatment available to adolescents who need substance abuse treatment. In an effort to bridge the language barrier, the AFF coordinator stated that “We have a clinician who can translate during sessions.” AFF Client needs AFF coordinators were asked if there were any services clients needed but were not available through their agency or in their local community. One coordinator reported the need for men-only groups that could not be filled at the current time without additional staffing. Another coordinator reported seeing an increase in the number of clients needing methadone treatment which is limited in their local area. Another need cited by sev­ eral coordinators was additional housing, especially for clients that have criminal histories. In many situations, a client who has been convicted of a felony is excluded from public housing services, and often from private housing as well. Transportation services in rural parts of the state continue to be a challenge. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report This page has been left blank intentionally. Center for Applied Behavioral Health Policy 53 CHAPTer 6. summArY AnD ConClusions This report summarizes the key processes and outcomes of the Arizona Families FIRST program (AFF), now in its seventh year of operation. The continued commitment of the legislature to critically examine the pro­ cesses and outcomes of this highly innovative program has afforded the opportunity to study the development and continued operations of a pro­ gram unique in its scope and focus. The utilization of information gath­ ered from a variety of sources, including administrative data, focus groups, key informant interviews, and service utilization records provide diverse perspectives to address fundamental questions: • First, is the AFF program serving its intended target population? • Second, are individuals served and provided services in a manner consistent with that articulated in the enabling legislation of the program and operationalized by DES and its contracts with providers? • Third, are program participants realizing outcomes in terms of enhanced child safety and family functioning, enhanced parental employment, and sobriety, for which the program was designed? is the AFF Program serving its intended Target Population? In SFY 2008, a total of 5,722 individuals were served by the program, rep­ resenting a 28% increase from SFY 2007, and continuing a steady growth in the number of individuals served. Nearly 70% of those individuals were new clients to the program, with the balance of clients representing indi- Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 54 viduals referred and assessed in SFY 2007 but continuing to receive ser­ vices in SFY 2008. Approximately seven out of 10 (72%) of all clients served by AFF are mothers, slightly more than half of whom reported they were single and had never been married. Twenty-eight percent of clients iden­ tify themselves to be Latino; 7% identify themselves as African American. Nearly three quarters of the clients were unemployed and slightly less than half (47%) report their highest educational level to be a high school diploma or equivalent. Eighty-five percent of clients had at least one in­ vestigative report for suspected child maltreatment open with CPS at the time of their enrollment in the AFF program; 22% of those reports had been classified as “substantiated”.25 At the time of program enrollment, two thirds (65.8%) of clients self-re­ ported that they have abused alcohol or used illicit substances in the im­ mediately preceding 30 days. Alcohol, cannabis, and methamphetamine continue, as in previous years, to reflect the more commonly reported substances of abuse, all reported at comparable rates among one third of those clients reporting use. As such, these data suggest that the AFF pro­ gram and its network of providers throughout the state continue to serve the intended target population: families involved in the Child Protective Services system wherein parental substance abuse and/or employment is deemed to be a significant factor impacting child safety and family func­ tioning. Further, the continuing growth in the number of clients served suggests that the need for the services offered through the AFF program continues to outstrip the availability of those services. Among Those individuals served, Are They Being Provided services in A manner Consistent With That Articulated in The enabling legislation of The Program? Services data collected from the local AFF contracted providers and matched with information obtained from DBHS suggest that nearly all of the clients enrolled in the AFF program during SFY 2008 received some form of service, with treatment and support services being accessed by 91% and 96% respectively of all clients. Slightly greater than one-half of clients were provided medical services, with fewer than one in five clients receiving any form of inpatient, residential treatment, or rehabilitation services. Among those clients accessing support services, case manage­ ment, transportation, and flex funds were the more commonly report­ ed services. Among those clients accessing treatment services, screening, evaluation and assessment along with family counseling were the more commonly reported services. Services that were reported rarely included child care, individual counseling, or rehabilitation services in general (in­ A substantiated finding is one in which the facts of a report provide a reasonable ground, i.e., some credible evidence, to believe that abuse or neglect occurred (Arizona Department of Economic security, Division of Children, Youth and families. Children’s services Manual. Retrieved from www.azdes.gov/ dcyf/cmdps /cps/Policy/serviceManual.htm on february 3, 2009). 25 Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 55 cluding skills training and psychoeducation). The relative amounts of service varied widely not only among clients (re­ flective of the individualization of services), but also among the AFF pro­ viders. Using the number of encounters (billing statements – generally corresponding 1:1 with each discrete service event) suggests that clients generally receive more support services (e.g., case management) and resi­ dential treatment services as compared to other services. There was wide variation in the relative amounts of service (expressed as the median num­ ber of encountered per client ) across the six DES districts and the mixture of services within these districts. Generally, clients served in DES District II received significantly less service in every service category, as compared to clients in all other DES districts. These data suggest that clients served by the AFF program are most likely (nearly 100%) to receive case man­ agement services, and moderately likely (50% - 75%) to be assessed and provided family counseling services. The relative amounts of services that clients are provided is inconsistent across the DES districts wherein the AFF providers are located. Future research could address the reasons for these variations and the relationships between the types and amounts of services provided to clients and the characteristics and outcomes achieved by these clients. In addition to the provision of a comprehensive continuum of services to clients, the AFF program is designed to provide outreach and engagement services on a timely basis. Providers are also mandated to conduct urinaly­ sis of all clients, on average twice per month. With regard to the timeliness of services, the data contained in this report indicate that, on average, clients are contacted by the AFF provider in the community in less than 48 (1.8 days) hours after a referral has been issued, representing a reduc­ tion of approximately a half day from the SFY 2007 reported timeliness of 2.34 days. Information provided by the AFF providers indicates significant variation in the use of urinalysis to detect substance use and substantial under utilization of urinalysis across all providers. For those clients whose cases were closed in SFY 2008, the average number of urinalyses (UAs) conducted per client was 8.5 (standard deviation = 17.97), ranging from a high of 27.3 (DES III) average UAs per client in DES District III to a low of 4.5 average UAs per client in DES District I. Clients across the state are re­ ceiving an average of 2.01 UAs for every 30 days that they are enrolled in the AFF program, in alignment with AFF program specifications. As such, while only half of all program participants are being provided UAs, those that are receiving UAs are doing so at an appropriate rate. Are Program Participants realizing The outcomes For Which The Program Was Designed? Three areas of client functioning are assessed as part of the AFF evalua­ tion plan. These include: child safety and family reunification; parental Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 56 sobriety/reduction in substance use; and parental employment. In SFY 2008, parents who entered the AFF program with a substantiated report of child maltreatment experienced a recurrence (filing of an additional substantiated report) of only 2%, representing less than half the national average of six-month recurrence of 5.4%. Among the more than 4,000 children of parents served in the AFF program that had been placed in out-of-home placements in SFY 2008, 54% were still in out-of-home placements at the end of the fiscal year, representing a 30% reduction in the number of children in out of home placements. Just under half (45%) of all children in out-of-home placements achieved permanency in SFY 2008, up significantly from the SFY 2007 AFF permanency rate of 25%. As such, these data indicate that among the families served in the AFF pro­ gram, child safety (as expressed as the recurrence of a report of suspected child maltreatment) is reduced significantly, and permanency placement for children (expressed as reunification with their parents) has improved significantly. Current outcomes among AFF participants regarding their employment and continued abuse of alcohol and other illicit drugs are less impressive and present continued opportunities for improvement. While 90% of all of the urinalyses were negative, the relative rates of selfreported substance use and employment remain unchanged among those clients discharged from the AFF program. At the time of closure, only 1.5% more clients report that they had used no alcohol or other illicit substance in the past 30 days compared to intake. Likewise, the proportion of clients reporting their employment status as “employed” increased from 26.3% at intake to 30.6% at discharge. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 57 RECOMMENDATIONS This program, representing a high degree of inter-agency collaboration between DES and DHS, served as a stimulus for Executive Order 2008-01 directing executive branch agencies to take steps that enhance the avail­ ability of substance abuse treatment services for families involved with Child Protective Services. During this past year, enhanced efforts at the detection, referral, and joint processing of substance abusing parents have been initiated and are reflected in the performance indicators of this highly innovative program. Further, this program continues to demon­ strate superior performance relative to child safety and permanency plan­ ning, enhanced by strategies implemented in accordance with Strength­ ening Families – A Blueprint for Realigning Arizona’s Child Welfare System. The very nature of this highly innovative program presents its greatest challenge and opportunity. The interplay between two governmental agencies (Department of Economic Security and Department of Health Services) with unique contracting and reporting processes, and the differ­ ences observed in some of the service and outcome data may well be a by-product of blending data obtained from both systems. Three specific areas wherein the interagency nature of this program may be impeding an accurate portrayal of program performance include the following: • Differences in the services reporting requirements of DES and DBHS impede adequate monitoring of the consistency of AFF service provision statewide. DES may want to convene a workgroup with DBHS representatives to examine ways in which DES-contracted treatment services can align with the DBHS Service Matrix. • Past reporting requirements, particularly with regard to substance use and employment, limit the usefulness of the outcome findings from the AFF program. DES may want to examine AFF provider contracts, to ensure that employment status and self-reported substance use patterns are re-assessed at the time of program discharge. • Regional variations in AFF service delivery suggest areas for enhanced program monitoring and technical assistance. DES may want to convene providers and the evaluation team to examine the causes for regional variations in key practice areas. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report This page has been left blank intentionally. Center for Applied Behavioral Health Policy 59 APPenDiCes Appendix A: Background Information on AFF Appendix B: Evaluation Plan Appendix C: Outreach and Engagement by AFF Provider Appendix D: AFF Client Demographic Characteristics by DES District Appendix E: Substance Use Patterns by DES District Appendix F: Taxonomy of DES and DBHS Services Appendix G: Service Access and Service Mix by DES Districts Appendix H: Service Utilization by DES Districts Appendix I: Days in Care by DES District Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 60 Appendix A: Background Information on the Arizona Families F.I.R.S.T. Program The AFF program is administered jointly by the Arizona Department of Eco­ nomic Security/Division of Children, Youth and Families (ADES/DCYF) and the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS), with DES designated as the lead agency. The legis­ lation established a statewide program for substance disordered 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 disorder in families is a major prob­ lem 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 lime limits established under the TANF block grant were also factors behind the legislation. The purpose of AFF is to develop community partnerships and programs for families whose substance disorder is a barrier to maintaining, preserv­ ing, or reunifying the family, or is a barrier to maintaining self-sufficien­ cy in the workplace. The joint Substance Abuse Treatment Fund was es­ tablished 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 the RBHAs) and other entities such as faith based organizations, domestic violence agencies, and social service agencies. The Arizona Legislature mandated in ARS 8-884 that the following out­ come goals 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. • 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. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 61 The initial AFF program Steering Committee26 required that the follow­ ing 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 DES to implement a community substance abuse prevention and treat­ ment program under Arizona Families F.I.R.S.T. The DES district geographic service areas, AFF provider agencies and Regional Behavioral Health Au­ thorities (RBHA) during the report period are summarized in the following table. The initial Aff program steering Committee was a policy committee chaired by the Governor’s office that pro­ vided guidance and oversight to the program during the start-up phase of the program. The committee disbanded after the initial start-up year of program operations. 26 list of Des Districts, Counties, AFF Providers, and rBHAs DES District County AFF Provider Agency Regional Behavioral Health Authority I Maricopa TERROS Magellan II Pima Community Partnership of Southern Arizona (CPSA) Community Partnership of Southern Arizona (CPSA) III Coconino Arizona Partnership for Children (AzPaC-Coconino) Northern Regional Behavioral Health Authority (NARBHA) III Yavapai Arizona Partnership for Children (AzPaC -Yavapai) Northern Regional Behavioral Health Authority (NARBHA) III Apache and Navajo Old Concho Community Assistance Center Northern Regional Behavioral Health Authority (NARBHA) IV Yuma Arizona Partnership for Children (AzPaC -Yuma) IV La Paz WestCare Arizona IV Mohave WestCare Arizona Northern Regional Behavioral Health Authority (NARBHA) V Gila and Pinal Horizon Human Services Cenpatico Behavioral Health of Arizona, Inc VI Cochise, Graham, Greenlee, and Santa Cruz Southern Arizona Behavioral Health Services (SEABHS) Community Partnership of Southern Arizona (CPSA) Cenpatico Behavioral Health of Arizona, Inc Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Did the AFF program improve the availability of drug treatment services in each catchment area? How? Did the AFF program improve the timeliness of drug treatment services in each catchment area? How? Clients’ perceptions of services offered by the program Clients’ perception of whether service needs are met Client contact with case manager Program capacity Service gaps Service additions or deletions Perception of sufficiency of community’s services Clients’ perceptions of time frames within which they receive services Number of days between referral & screening Number of days between screening and assessment Number of days between assessment & service delivery plan Staff perception of time frames in which clients receive services Barriers to receiving services Role of collaborative partnerships Number of days between referral & screening; Number of days between screening and assessment; Number of days between assessment & service plan completion Number of days between service plan and first treatment service Engagement rate: # receiving at least one treatment service / # of referrals x 100% Retention Rates: 30 Days: 2+ treatment services within first 30 days AFF participants Key stakeholders AFF program managers AFF participants Key stakeholders AFF program managers ADHS/DBHS CIS data for RBHA providers AFF provider service data Data Sources Focus groups Interviews Focus groups Interviews ADHS/DBHS electronic data files Provider electronic data files Method of Data Collection Increase the availability, timeliness and accessibility of substance abuse treatment to promote recovery from alcohol and drug problems. 3. Variable Increase the availability, timeliness and accessibility of substance abuse treatment to achieve self-sufficiency through employment. 2. Research Questions 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. Outcome Goals – ARS 8-884 APPenDiX B: AFF evaluation Plan for FY Julu 1, 2007-June 30, 2008 Annually Annually Annually Annually Annually Monthly Timeframe Qualitative analyses Qualitative analyses Qualitative analyses Descriptive statistics Proposed Analysis College of Public Programs, Arizona state Univeristy 62 How did improvements promote recovery from drug and alcohol problems? How did improvements affect TANF participants’ ability to achieve selfsufficiency through employment? How did improvements result in the reunification with birth families for children who had been placed in out of home care? How did improvements affect family stability and permanency for children in foster care or other out-of­ home placement? How did improvements in timeliness, availability, and accessibility affect child safety? Did the AFF program improve the accessibility of drug treatment services in each catchment area? How? Research Questions AFF client drug screens Drug and alcohol use past 30 days Drug screens Date file submitted by providers ADHS/DBHS CIS data for RBHA providers AFF Provider service data Focus groups DES electronic data file AZTEC AFF participants DES electronic data file DES electronic data file Focus groups DES electronic data file DES electronic data file Focus groups Interviews Method of Data Collection JAS ADHS/DBHS core assessment Client perceptions of ability to achieve self-sufficiency Receipt of TANF Secured employment Maintain employment status for 90 days Lose employment status and regain TANF benefits Family reunification DES CHILDS data set AFF participants DES CHILDS data set Adoption Family reunification Guardianship Long-term foster care Child(ren) remaining at home while caregiver receives treatment Client perceptions of family stability DES CHILDS data set AFF participants Key stakeholders AFF program managers Data Sources Subsequent allegations of abuse & neglect Subsequent birth with prenatal drug exposure? Clients’ perceptions of whether they actually receive services they need Clients’ perceptions of how well they understand how service delivery stem operations Proximity of services Contact with case managers Service utilization Wait time Hours of operation Transportation Perception of clients’ access to services Barriers to receiving services Role of collaborative partnerships Role of referral system Variable Monthly Annually At initial assessment Change in status Every 12 months At closure Annually Annually Annually Annually Annually Annually Annually Annually Timeframe Descriptive statistics Longitudinal analysis Qualitative analyses Descriptive statistics Descriptive statistics Qualitative analyses Qualitative analyses Descriptive statistics Descriptive statistics Qualitative analyses Qualitative analyses Proposed Analysis Center for Applied Behavioral Health Policy 63 Reports of suspected child abuse/neglect Foster care entry For those who had abuse/neglect allegations at program entry, what percent subsequently had children placed in foster care? Service plan completion Reunification Adoption Was there an increase in the number of children in out-of-home care that achieved permanency? What percentage of clients successfully completed their treatment service plans? Days in foster care Drug and alcohol use past 30 days Drug screens Was there a decrease in the number of days in foster care per child? Was there a decrease in the frequency of alcohol and/or drug use? Length of time receiving TANF Average monthly amount received from TANF Secured employment Maintained employment at 90 day follow-up Reports of suspected child abuse/neglect Was there a reduction in the recurrence of child abuse and/or neglect? Was there an increase in the number of families either obtaining or maintaining employment? Variable AFF Provider service data ADHS/DBHS CIS data for RBHA providers DES CHILDS data set DES CHILDS data set ADHS/DBHS core assessment AFF participant drug screens DES JAS data set DES AZTEC data set DES CHILDS data set DES CHILDS data set Data Sources Reduction in the recurrence of child abuse and/or neglect; 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 Research Questions 1. 2. 3. 4. Performance Measures – Scope of Work, III-1: Required Performance Measures: ADHS/DBHS CIS data for RBHA providers AFF Provider service data DES electronic data file DES electronic data file Date file submitted by providers DES electronic data file DES electronic data file DES electronic data file Method of Data Collection Annually Monthly Annually Descriptive statistics Descriptive statistics Descriptive statistics Descriptive statistics At initial assessment Change in status Every 12 months At closure Annually Descriptive statistics Descriptive statistics Descriptive statistics Proposed Analysis Annually Annually Annually Timeframe College of Public Programs, Arizona state Univeristy 64 Individuals referred who have engaged in substance abuse treatment program and do not have a subsequent substantiated CPS report after 6 months of enrollment. # of children of referred individuals who participate in substance abuse treatment that achieve permanency through reunification, adoption or guardianship following at least 6-months parental participation in the substance abuse treatment program. Goal #3: To establish permanency for the children of AFF program participants Number of referrals for substance abuse treatment Participants who have engaged in at least one therapeutic service Participants who have engaged in AFF treatment for 3 months Participants who have engaged in AFF treatment for 6 months Variable Goal #2: To reduce the recurrence of child abuse and neglect of AFF program participants’ children Goal 1: To promote recovery from alcohol and drug abuse for AFF program participants Research Questions Scope of Work, III-4: DES Strategic Plan Key Indicators DES/CPS data set AFF provider service data DES/CPS data set Annually Monthly AFF Provider electronic data files DES/CPS electronic data files Annually Monthly DES/CPS electronic data files AFF Provider electronic data files ADHS/DBHS electronic data files ADHS/DBHS CIS data for RBHA providers AFF provider service data Monthly AFF Provider electronic data files AFF Provider service data Annually Timeframe Method of Data Collection Data Sources Descriptive statistics Descriptive statistics Descriptive statistics Proposed Analysis Center for Applied Behavioral Health Policy 65 I AFF Provider TERROS Number of Days from Referral to Outreach Number of Clients 2542 946 Minimum 0 0 Median 1 1 Maximum 280 69 Mean 2.1 1.4 Standard Deviation 11.2 3.8 Number of Days from Referral to Service Acceptance Number of Clients 2518 298 Minimum 0 0 Median 0 8 Maximum 342 110 Mean 8.5 12.4 Standard Deviation 43.0 13.2 Number of Days from Referral to Assessment Number of Clients 1858 225 Minimum 0 0 Median 18 11 Maximum 296 286 Mean 28.1 24.6 Standard Deviation 34.1 41.3 DES Districts 195 0 0 46 1.6 5.3 171 0 6 54 9.2 11.2 92 0 14 132 21.5 20.8 61 0 0 8 0.7 1.4 51 0 2 95 8.8 16.7 22 7 19 197 33.9 45.4 4 7 20 22 17.3 6.9 174 0 0 1 0.0 0.1 174 0 0 19 0.2 1.4 118 0 15 197 24.0 27.9 396 0 0 95 4.7 10.3 430 0 0 46 0.9 3.8 14 9 37 86 39.2 22.0 69 0 0 5 0.1 0.7 66 0 0 27 2.6 4.9 20 1 6.5 79 16.1 22.1 147 0 0 0 0.0 0.0 145 0 0 8 0.8 1.5 Year to Date Average Number of Days From Referral to Services Year to Date July 2007-June 2008 II III III III III IV IV AzPaC AzPaC Old Total AzPaC CPSA Coconino Yavapai Concho Yuma West Care Appendix C: outreach and engagement by AFF Provider 34 1 17 86 26.4 24.6 216 0 0 5 0.1 0.7 211 0 0 27 1.4 3.1 IV Total 67 0 7 110 13.3 21.9 147 0 0 5 0.1 0.7 76 0 7 170 20.5 34.5 64 0 0 0 0.0 0.0 101 0 0 8 0.8 1.5 SEABHS Horizon 135 0 0 10 0.5 1.5 VI V 2378 0 16 296 26.8 34.3 3639 0 0 342 7.8 37.5 4365 0 1 280 1.8 9.0 Total College of Public Programs, Arizona state Univeristy 66 Average Age Female Male Unknown Total 30.30 2231 770 0 3001 TERROS I Race/Ethnicity American Indian/Alaska Native 120 Asian 3 Black/African America n 298 Caucasian/White 2534 Native Hawaiian/Pacific Islander 3 Multiple Races 33 Other 0 Unknown 10 Total 3001 Ethnicity Hispanic/Latino 835 Not Hispanic/Latino 2166 Unknown 0 Total 3001 Average Age Gender DES Districts AFF Providers 16 0 1 38 0 0 8 21 84 13 44 27 84 452 858 44 1354 30.90 62 20 2 84 39 6 72 1186 1 2 7 41 1354 30.90 885 452 17 1354 33 250 27 310 6 0 5 277 1 0 15 6 310 31.10 212 97 1 310 22 152 5 179 29 0 2 117 5 0 11 15 179 30.50 119 55 5 179 65 39 1 105 2 0 2 41 0 0 58 2 105 32.00 88 16 1 105 20 181 5 206 8 1 1 173 1 0 18 4 206 31.70 153 53 0 206 57 142 25 224 8 0 9 170 1 0 12 24 224 29.00 178 45 1 224 94 141 24 259 5 2 8 194 4 0 16 30 259 29.80 195 64 0 259 AFF Participating Clients Demographics Year to Date July 2007 - June 2008 II III III III IV IV V VI AzPaC AzPaC Old AzPaC CPSA Coconino Yavapai Concho Yuma West Care Horizon SEABHS Appendix D: AFF Client Demographic Characteristics by Des District 1591 3973 158 5722 233 12 398 4730 16 35 145 153 5722 27.8% 69.4% 2.8% 100.0% 4.2% 0.2% 7.1% 84.9% 0.3% 0.6% 2.6% 2.7% 100.0% 72.4% 27.6% 0.5% 100.0% All Sites % 30.50 4123 1572 27 5722 Total Center for Applied Behavioral Health Policy 67 81.8% 56.7% 31.6% 1.4% 10.2% 1.3% 2.5% 0.3% 27.1% 29.4% 1.7% 4.3% 1.2% 0.6% Clients Reporting use Alcohol Benzodiazepines Cocaine/crack Hallucinogens Heroin/Morphine Inhalants Marijuana Methamphetamine Other drugs Other Narcotics Other sedatives Other Stimulants 35.6% 1.1% 31.0% 0.8% 3.6% 0.1% 37.3% 24.7% 4.2% 1.8% 0.1% 0.1% CPSA 1354 II DES Districts I AFF Providers Substances TERROS Total Participating Clients 3001 Appendix e: substance use Patterns by Des District 46.4% 0.0% 2.4% 3.6% 2.4% 1.2% 31.0% 33.3% 0.0% 0.0% 0.0% 0.0% 73.8% 35.2% 0.3% 1.9% 0.3% 1.6% 0.3% 35.2% 39.7% 0.6% 1.0% 0.3% 0.6% 75.8% III III AzPaC AzPaC Coconino Yavapai 84 310 36.9% 0.6% 2.2% 0.6% 0.6% 0.0% 34.1% 31.8% 1.7% 2.2% 0.0% 0.6% 68.7% III Old Concho 179 22.9% 0.0% 1.9% 0.0% 1.9% 1.0% 30.5% 44.8% 0.0% 0.0% 0.0% 0.0% 63.8% 35.0% 0.5% 3.4% 0.0% 1.5% 0.0% 29.6% 45.1% 1.0% 1.0% 0.0% 0.0% 74.8% 20.5% 0.9% 2.7% 0.0% 1.3% 0.4% 25.9% 41.1% 1.3% 3.1% 0.4% 0.4% 61.6% IV IV V AzPaC Yuma West Care Horizon 105 206 224 Participating Clients Substances Use 25.5% 0.4% 8.9% 0.4% 1.2% 0.4% 34.0% 30.9% 3.5% 2.3% 0.0% 0.4% 68.0% SEABHS 259 VI 1853 63 776 55 142 15 1752 1737 126 177 39 26 65.8% 32.4% 1.1% 13.6% 1.0% 2.5% 0.3% 30.6% 30.4% 2.2% 3.1% 0.7% 0.5% All Sites Total % 5722 College of Public Programs, Arizona state Univeristy 68 Center for Applied Behavioral Health Policy 69 Appendix F: Taxonomy of AFF and DBHs services service labels and Definitions recognized by the Department of economic security substance Abuse education: These services are short-term in duration and are appropriate for clients who are unwilling to commit to more intensive services. Attendance at substance abuse awareness groups and individual counseling to consider the effect of substance abuse in one’s life would be included under substance abuse education. outpatient Treatment services: Outpatient treatment services are intend­ ed for clients who can benefit from therapy, are highly motivated, and have a strong support system. These clients need a minimum level of in­ tervention and other supports. Service providers are required to provide a minimum of three hours per week of individual or group treatment (or a combination of both). intensive outpatient Treatment services: Intensive outpatient services are intended for clients who can benefit from structured therapeutic in­ terventions, are motivated, and have some social supports. This continu­ um of services is appropriate for clients who need a moderate amount of therapy and supports. At a minimum, service providers are expected to provide nine hours per week of therapy for a minimum of eight weeks. This therapeutic involvement can include individual, group, and family therapy; substance abuse awareness; and social skills training. residential Treatment: Residential treatment services are intended for cli­ ents who need an intensive amount of therapeutic and other supports to gain sobriety. These services include 24-hour care and supervision. Similar to intensive outpatient treatment, residential treatment can include indi­ vidual counseling, group therapy, family therapy, substance abuse aware­ ness, and social skills training. Residential treatment may include children residing with parents while the parents are in treatment. Aftercare services: Aftercare services are provided for clients at the end of their treatment plan through the AFF provider. It should be noted that aftercare service is not a recognized service category within the ADHS/ DBHS system. At a minimum, the aftercare plan includes a relapse preven­ tion program, identification and linkage with supports in the community that encourage sobriety, and available interventions to assist clients in the event that relapse occurs. Development of the aftercare plan is expected to begin while the client is in treatment. It should be noted that while aftercare is not a billable service under the ADHS/DBHS covered services guide, there is an expectation that RBHA service plans will address recov­ ery management and relapse management. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report College of Public Programs, Arizona state Univeristy 70 service Domains/Definitions recognized by the Division of Behavioral Health services.1 Treatment services: Services provided by or under the supervision of be­ havioral health professionals to reduce symptoms and improve or main­ tain functioning. These services have been further grouped into three subcategories: Behavioral Health Counseling and Therapy; Assessment, Evaluation and Screening Services; and Other Professional. rehabilitation services: These services include the provision of education, coaching, training, demonstration and other services, including securing and maintaining employment to remediate residual or prevent anticipat­ ed functional deficits. Four subgroups of services are defined. medical services: Medical services are provided by or ordered by a licensed physician, nurse practitioner, physician assistant, or nurse to reduce a per­ son’s symptoms and improve or maintain functioning. These services are further grouped into the following subcategories: Medication; Labora­ tory; Medical Management; and Electro-Convulsive Therapy. support services: Support services are provided to facilitate the delivery of or enhance the benefit received from other behavioral health services. These services are further grouped into the following categories: case management; personal care services; family support; self-help/peer ser­ vices; therapeutic foster care services, unskilled respite care; supported housing; sign language or oral interpretive services; supportive services; and transportation. Crisis intervention services: Crisis intervention services are provided to a person for the purpose of stabilizing or preventing a sudden, unantici­ pated, or potentially deleterious behavioral health condition, episode or behavior. Crisis intervention services are provided in a variety of settings. inpatient services: Inpatient services (including room and board) are pro­ vided by an OBHL licensed Level I behavioral health agency and include hospitals, sub-acute facilities, and residential treatment centers. These facilities provide a structured treatment setting with daily 24-hour super­ vision and an intensive treatment program, including medical support ser­ vices. residential services: Residential services are provided on a 24-hour basis and are divided into the following subcategories based on the type of fa­ cility providing the services: Level II behavioral health residential facilities and Level III behavioral health residential facilities. Behavioral Health Day Programs: Day program services are scheduled on a regular basis either on an hourly, half day or full day basis and may include services such as therapeutic nursery, in-home stabilization, after school 1. see http://www.azdhs.gov/bhs/covserv.htm Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report Center for Applied Behavioral Health Policy 71 programs, and specialized outpatient substance abuse programs. These programs can be provided to a person, group of person, and/or families in a variety of settings. Day programs are further grouped into the follow­ ing three subcategories: supervised; therapeutic; and psychiatric/medical. Arizona families f.I.R.s.T. Program 2008 Annual Evaluation Report DES Districts Participating Clients Services Treatment Services Rehabilitation Services Medical Services Support Services Crisis Intervention Services Inpatient Services Residential Services Behavioral Health Day Prgms I 3001 # % 2840 94.6% 400 13.3% 2313 77.1% 2951 98.3% 283 9.4% 23 0.8% 170 5.7% 270 9.0% AFF Participating Clients Services II III IV V VI Statewide 1354 573 311 224 259 5722 # % # % # % # % # % # % 1160 85.7% 517 90.2% 279 89.7% 188 83.9% 219 84.6% 5203 90.9% 310 22.9% 181 31.6% 87 28.0% 62 27.7% 96 37.1% 1136 19.9% 558 41.2% 362 63.2% 237 76.2% 100 44.6% 164 63.3% 3734 65.3% 1236 91.3% 558 97.4% 303 97.4% 216 96.4% 252 97.3% 5516 96.4% 310 22.9% 35 6.1% 18 5.8% 17 7.6% 47 18.1% 710 12.4% 23 1.7% 31 5.4% 8 2.6% 2 0.9% 13 5.0% 100 1.7% 203 15.0% 48 8.4% 12 3.9% 23 10.3% 22 8.5% 478 8.4% 47 3.5% 21 3.7% 1 0.3% 2 0.9% 0 0.0% 341 6.0% Appendix g: service Access and service mix by Des District College of Public Programs, Arizona state Univeristy 72 Treatment Services Family Counseling Individual Counseling Group Counseling Assessment, Evaluation and Screening Services Other Treatment Services by Professionls Intensive Oupatient Services Outpatient Services Rehabilitation Services Skills Training and Development Behavioral Health Prevention/Promotion Education Psychoeducational Services Medical Services Medication Services Laboratory Services Medical Management Pharmacy Services Support Services Case Management Personal Care Services Home Care Training Family Self-Help/Peer Services Unskilled Respite Care Supported Housing Sign Language Services Flex Fund Services Transportation Child Care Services After Care Other Support Services DES Districts Services 96.7% 6.0% 5.6% 23.3% 48.5% 47.5% 26.0% 2745 169 159 661 400 194 190 104 2313 79 2091 523 587 2951 2889 25 34 347 0 40 3 1794 1011 0 77 333 97.9% 0.8% 1.2% 11.8% 0.0% 1.4% 0.1% 60.8% 34.3% 0.0% 2.6% 11.3% 3.4% 90.4% 22.6% 25.4% 52.7% 55.5% 37.6% % # 2840 1497 1575 1067 I 19 185 558 32 237 380 382 1236 1065 17 36 177 6 25 12 600 195 0 12 4 171 192 0 140 310 910 # 1160 654 9 3 % 86.2% 1.4% 2.9% 14.3% 0.5% 2.0% 1.0% 48.5% 15.8% 0.0% 1.0% 0.3% 5.7% 42.5% 68.1% 68.5% 6.1% 59.7% 55.2% 16.6% 0.0% 12.1% 78.4% 56.4% 0.8% 0.3% II 44 96 362 2 249 192 164 558 553 8 12 37 0 44 1 225 205 1 41 109 97 24 35 35 181 434 # 517 342 3 20 % 99.1% 1.4% 2.2% 6.6% 0.0% 7.9% 0.2% 40.3% 36.7% 0.2% 7.3% 19.5% 0.6% 68.8% 53.0% 45.3% 24.3% 53.0% 53.6% 4.6% 6.8% 6.8% 83.9% 66.2% 0.6% 3.9% III AFF Participating Clients Services Appendix H: service utilization by Des Districts 47 37 237 3 212 71 56 303 291 7 16 28 0 5 1 122 78 4 37 154 34 12 0 29 87 240 # 279 181 2 25 % 96.0% 2.3% 5.3% 9.2% 0.0% 1.7% 0.3% 40.3% 25.7% 1.3% 12.2% 50.8% 1.3% 89.5% 30.0% 23.6% 54.0% 42.5% 39.1% 4.3% 0.0% 10.4% 86.0% 64.9% 0.7% 9.0% IV 4 43 100 2 65 45 43 216 207 5 4 67 14 0 0 62 105 0 0 2 35 22 0 25 62 143 # 188 152 13 5 % 95.8% 2.3% 1.9% 31.0% 6.5% 0.0% 0.0% 28.7% 48.6% 0.0% 0.0% 0.9% 2.0% 65.0% 45.0% 43.0% 6.5% 69.4% 56.5% 11.7% 0.0% 13.3% 76.1% 80.9% 6.9% 2.7% V 9 28 164 0 108 79 79 252 248 9 13 95 0 5 11 84 94 0 7 68 85 23 15 71 96 186 # 219 152 2 0 % 98.4% 3.6% 5.2% 37.7% 0.0% 2.0% 4.4% 33.3% 37.3% 0.0% 2.8% 27.0% 0.0% 65.9% 48.2% 48.2% 9.4% 29.2% 88.5% 10.5% 6.8% 32.4% 84.9% 69.4% 0.9% 0.0% VI 313 493 3734 118 2962 1290 1311 5516 5253 71 115 751 20 119 28 2887 1688 5 174 670 616 442 209 961 1136 4658 95.2% 1.3% 2.1% 13.6% 0.4% 2.2% 0.5% 52.3% 30.6% 0.1% 3.2% 12.1% 3.2% 79.3% 34.5% 35.1% 27.6% 43.4% 54.2% 8.5% 4.0% 18.5% 89.5% Statewide # % 5203 2978 57.2% 1604 30.8% 1120 21.5% Center for Applied Behavioral Health Policy 73 257 Therapeutic Behavioral Health Services and Day Programs 95.2% 5.9% 1.2% 2 16 0.0% 0 Supervised Behavioral Health Treatment and Day Programs 100.0% 170 270 73.1% 207 23 170 47 0 47 0 0 203 294 23 203 30 44.2% # 125 % 310 I 283 # Crisis Intervention Services Crisis Intervention Services Mobile Crisis Intervention Services Stabilization Inpatient Services Residential Services Behavioral Health Short-Term Residential Level II Behavioral Health Long-Term Residential Level III Child Residential Services w/Parent Behavioral Health Day Programs DES Districts Services 9.7% % 100.0% 0.0% 0.0% 0.0% 100.0% 94.8% II 21 0 21 0 0 48 10 31 48 26 35 # % 100.0% 0.0% 0.0% 0.0% 100.0% 28.6% 74.3% III AFF Participating Clients Services Appendix H: service utilization by Des Districts (continued) 1 0 1 0 1 11 3 8 12 15 18 # % 100.0% 0.0% 0.0% 8.3% 91.7% 16.7% 83.3% IV 2 0 2 0 1 22 4 2 23 13 17 # % 100.0% 0.0% 0.0% 4.3% 95.7% 23.5% 76.5% V 0 0 0 0 0 22 27 13 22 23 47 # % 0.0% 0.0% 0.0% 0.0% 100.0% 57.4% 48.9% VI 328 16 341 2 2 476 545 100 478 232 710 96.2% 4.7% 0.4% 0.4% 99.6% 76.8% 32.7% Statewide # % College of Public Programs, Arizona state Univeristy 74 Center for Applied Behavioral Health Policy 75 Appendix i: Days in Care by Des District Days in Care For Children Reunified with Parent(s) or Caregiver Discharged Reunified Minimum Days in care Maximum Days in care Average Days in Care I 262 1 976 147 68.36 II 75 2 990 72 185.55 III 44 1 353 56 101.60 IV 26 6 284 90 117.30 V 39 3 867 123 257.27 VI 23 1 489 101 117.02 Total 469 1 990 44 156.21 Still in Care Minimum Days in care Maximum Days in care Median Days in Care Average Days in Care 784 0 1166 193 154.63 369 11 1198 163 155.03 119 8 702 158 173.80 251 9 311 1337 343.03 80 15 436 215 198.40 60 25 848 148 125.40 1517 0 1198 177 147.67 Relatives Minimum Days in care Maximum Days in care Median Days in Care Average Days in Care 35 1 10 5 2.11 3 3 24 3 12.12 1 28 28 28 N/A 5 5 116 5 55.10 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 44 1 116 5 21.61 Adoption Minimum Days in care Maximum Days in care Median Days in Care Average Days in Care 2 1113 1113 1113 0 0 N/A N/A N/A N/A 1 439 439 439 N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 3 439 1113 1113 389.13 Emancipation Minimum Days in care Maximum Days in care Median Days in Care Average Days in Care 1 566 566 566 N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 1 566 566 566 N/A Guardianship Minimum Days in care Maximum Days in care Median Days in Care Average Days in Care 44 1 685 5 186.85 1 181 181 181 N/A 4 6 498 197.5 224.80 2 4 4 4 0.00 0 N/A N/A N/A N/A 3 5 345 345 196.30 54 1 685 6 185.47 Transfer to Agencies Minimum Days in care Maximum Days in care Median Days in Care Average Days in Care 9 1 567 167 197.419 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 9 1 567 167 197.419 College of Public Programs, Arizona state Univeristy 76 Days in Care For Children Reunified with Parent(s) or Caregiver District Runaway Minimum Days in care Maximum Days in care Median Days in Care Average Days in Care I 0 N/A N/A N/A N/A II 1 8 8 8 N/A III 0 N/A N/A N/A N/A IV 0 N/A N/A N/A N/A V 0 N/A N/A N/A N/A VI 0 N/A N/A N/A N/A Total 1 8 8 8 N/A Death Minimum Days in care Maximum Days in care Median Days in Care Average Days in Care 1 78 78 78 N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 0 N/A N/A N/A N/A 1 78 78 78 N/A This page has been left blank intentionally. CenTer For APPlieD BeHAviorAl HeAlTH PoliCy College of Public Programs Arizona state university street/shipping Address: 3404 W. Cheryl Drive, Ste. A-250 Phoenix, AZ 85051 mailing Address: P.O. Box 37100, Mail Code 3252 Phoenix, AZ 85069-7100 (602) 942-2247 (602) 942-0779 Fax www.CABHP.Asu.eDu