Outcomes of a treatment foster care pilot for youth with complex multi-system needs

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1 Outcomes of a treatment foster care pilot for youth with complex multi-system needs Melissa Johnson Kimberly McGrath Mary Armstrong Norín Dollard John Robst René Anderson Presented at the 28th Annual Research and Policy Conference on Child, Adolescent, and Young Adult Behavioral Health, March 23rd, 2015, Tampa, Florida

2 Support This work is supported in part by the Florida Agency for Health Care Administration contract #MED134

3 Why enhanced therapeutic foster care? Many interventions targeted to youth with justice involvement are not effective (Henggeler & Schoenwald, 2011). Blueprints Initiative reviewed the evidence base for over 600 prevention and intervention programs Of the few found effective, Multidimensional Treatment Foster Care was included Evidence for the presence of a group contagion effect with delinquent youth in group settings (Lee & Thompson, 2009)

4 Why enhanced therapeutic foster care? Florida studies over the past five years suggest: There are large proportions of youth entering Statewide Inpatient Psychiatric Programs (SIPP) (42%, n=195) and Therapeutic Group Care (TGC) (31%, n=86) with juvenile justice contacts in the six months prior to placement The higher the proportion of justice-involved youth in SIPPs or TGC, the more likely youth treated in these settings will have higher rates of future criminal activity after discharge. Youth treated in Specialized Therapeutic Foster Care have lower rates of delinquent activity after discharge.

5 Florida Context No standardized practice model with evidence base for Specialized Therapeutic Foster Care Closure of youth commitment settings in Miami-Dade Statewide move towards adopting EBPs ReDirections (AHCA DJJ) and DCF Georgetown Crossover Youth Practice Model Wraparound--DCF

6 Implementation of a Pilot Program Engagement of system partners at state and community level Commitment to identify evidence-based model that is cost feasible statewide within Florida s publicly funded children s system Review of evidence base for therapeutic foster care Investigation of feasibility of Multidimensional Treatment Foster Care Decision to use Together Facing the Challenge

7 What is Together Facing the Challenge? Evidence-based model that includes training and coaching for treatment foster care supervisors and parents on: Supportive and involved relationships between supervisors and treatment parents; Effective use of behavior management strategies by treatment parents; and; Supportive and involved relationships between treatment parents and youth Farmer, E. M., Burns, B. J., Wagner, H. R., Murray, M. M., & Southerland, D. G. (2010)

8 What is Together Facing the Challenge? Foster parents are active members of the treatment team and are held accountable for behavioral interventions. Allows therapists the opportunity to focus on core clinical issues with their clients while still addressing behavioral concerns. Provides a structured and consistent framework for parents within a system which reduces differences between homes in the program. Provides clear, consistent and obtainable treatment goals for clients.

9 Study Purpose To implement and evaluate a small pilot study (n=10) of Together Facing the Challenge in Miami For feasibility in real world public sector settings, With fidelity to the supervision and teaching model, Tracking outcomes and costs.

10 Research Questions 1. What are the outcomes for children and youth enrolled in an enhanced therapeutic foster care model? 2. What are the program costs?

11 Population Inclusion criteria 9-17 years old History of juvenile justice involvement Referred by Miami-Dade multidisciplinary child welfare team for appropriate placement Meets criteria for Florida s Specialized Therapeutic Foster Care according to Medicaid handbook Is in the child welfare dependency system Is enrolled in Medicaid Assent and consent obtained, as well court authorization if applicable

12 Population (continued) Exclusion criteria Sex offenders (Felony sex offenses including kidnapping involving sex offenses, sexual assaults, sexual battery, lewd & lascivious, and other felony sex offenses) Violent offenders (Violent crime includes murder, forcible sex offenses, robbery, and aggravated assault) Axis I diagnosis of substance abuse

13 Data Collection Administrative data from Citrus, adult and youth justice, state mental health, and Medicaid management information systems Primary data collected from youth and their caregivers at baseline, every three months while in treatment, discharge, and post-discharge

14 Administrative Data Elements Age, race / ethnicity, gender, and diagnoses Completion of the program, run away behaviors, delinquent behaviors, permanency goal attainment, treatment plan goal attainment, academic outcomes (e.g., grades, suspensions, expulsions, referrals for behavior), response to treatment, positive interactions with adults and peers, and Baker Act initiations

15 Outcome Data Collected from Youth & Caregivers Child Health Questionnaire (Caregiver Report) Behavioral and Emotional Rating Scale Second Edition, (Caregiver & Youth Report) Child Behavior Checklist & Youth Self- Report (Youth and Caregiver Report) Strengths and Difficulties Questionnaire (Caregiver Report)

16 Pilot Findings Youth Demographics (n = 10) 40% Male 90% Black or African American 10% Hispanic / Latino 60% were years of age at baseline (range 13-17)

17 Diagnoses Diagnoses % (N=9) Conduct Disorder 66.7% Mood Disorder 55.5% Substance Abuse 44.4% Attention Deficit 33.3% Oppositional Defiant Disorder 33.3% Bipolar Disorder 22.2% Adjustment Disorder 11.1% Major Depressive Disorder 11.1%

18 BERS Strengths Quotient Index Baseline 3 month 6 month Discharge Caregiver Youth

19 Strengths and Difficulties Questionnaire SDQ Scale Proportion of youth scoring in the normal range Baseline (N =8) 3M (N=10) 6M (N=6) Discharge (N=8) Emotional Symptoms 62.5% 70% 66.7% 75% Conduct Problems 37.5% 40% 50% 25% Hyperactivity 50% 70% 83.3% 75% Peer Problems 50% 50% 33.3% 25% Prosocial 87.5% 50% 83.3% 50% Total Difficulties 0% 10% 0% 25%

20 CBCL Caregiver Report T- scores Baseline 3 months 6 months Discharge Internalizing Externalizing Total

21 Youth Self-Report T-scores Baseline 3 months 6 months Discharge Internalizing Externalizing Total Problem

22 In the past 4 weeks, how much did you worry / concern did you have about your child s * your child's attention or learning abilities your child's emotional wellbeing your child's physical health 0% 20% 40% 60% 80% 100% Discharge (n = 8) 6 months (n =6) 3 months (n =9) Baseline (n = 6) * Quit a bit or alot

23 Adverse Events All youth had JJ histories at admission, but only 4 had subsequent encounters (5 total encounters) 3 youth had involuntary examinations (4 total) 7 youth ran away while receiving services ranging from 2-21 days AWOL 4 youth required a higher level of care and were stepped up to SIPP (inpatient treatment)

24 Program Completion 6 youth successfully completed the ETFC program and were either reunified or stepped down to a lower level of care Median length of time in ETFC was 11 months for youth who completed the program Youth requiring more intensive inpatient treatment (n = 4) were all identified as having CSECinvolvement, which may explain why this program was not effective for them

25 Costs Costs favor 9 months of ETFC ($74K) over 9 months RTC ($112K) 6 six months of RTC and 3 months of community-based services ($79K) 6 months RTC and 3 months of Therapeutic Group Care (TGC, $103K) 6 months of RTC & 3 months of TFC ($92K) 9 months of TGC & 9 months community services ($86K) 9 months of ETFC ($74K) costs the same as 9 months of Juvenile commitment & 9 months group care plus overlay BH services ($78K)

26 Conclusions Training costs for Together Facing the Challenge are modest and sustainable (use a train-the trainer approach) Foster parents are able to learn and apply the ETFC skills Caregivers have a stable view of youth strengths. Youth s perceptions of their own strengths improved over time Caregivers report higher levels of difficulties with externalizing and total problem behaviors than the youth

27 Conclusions Caregivers report progress in integrating youth into their families over time with fewer disruptions Relatively few adverse incidents (JJ encounters and Baker Acts) Costs favor ETFC over RTC, RTC plus step down and JJ program costs)

28 Recommendations School is the biggest challenge as evidenced by caregiver and youth report on their strengths, and grade point average. Identifying ways to address runaways is crucial Engagement = there appears to be a honeymoon period in the first 3 months, then spikes, and then subsequent improvements

29 Challenges to Implementation Acquiring administrative or executive support and understanding within your agency of the implementation process is essential. Transitioning staff from Business as usual to implementation of new techniques and procedures can be challenging!

30 Challenges to Implementation Successful implementation requires constant training and education for system partners (i.e judicial system, CBC providers, GAL) regarding the program requirements and the treatment process. Incentives and rewards for participation in the evaluation process help keep clients and parents engaged throughout the treatment process.

31 Strengths & Successes This program provides an opportunity for intensive treatment services in the community for a population of clients that typically would not be served at this level of care. We are now integrated into the system of care in Dade county and we have a waiting list. Foster parents and staff are receptive to expanding the program.

32 Next Steps Working with Medicaid and its contract Managed Care Organizations to modify discharge criteria for STFC pilot programs to allow children the opportunity to benefit from one year of treatment services. Engaging in intensive foster parent recruitment efforts to facilitate program expansion. Agreement from the FL Department of Juvenile Justice to share in the program costs Work with Our Kids to move towards county-wide implementation of Together Facing the Challenge curriculum for all therapeutic foster parents,

33 Questions?

1. The youth is between the ages of 12 and 17.

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