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  • 1. Indicated Prevention:Bridging the Gap – One Person at a Time William W. Harris, BS, CADC-II and Jan Ryan, MA Riverside County Department of Mental Health Substance Abuse Program – Prevention Services 1
  • 2. Continuum of ServicesFilling the gap in the continuum of servicesbetween substance abuse prevention services andtreatment services has always been challenging.This is especially true in a county-operatedsubstance abuse services setting where treatmentand prevention funding come from differentsources and fiscal accountability requires strictseparation of funding for the provision oftreatment and prevention services. 2
  • 3. Providing Prevention Services to Individuals is anew concept to most Substance Abuse Programs Typically in past only seen in Student Assistance Programs Employee Assistance Programs Uncharted territory for most substance abuse and prevention providers 3
  • 4. Riverside County Statistics 4th Largest County in California in area and population 2009 Population estimate – 2,125,000 7,303 sq. miles in area - equivalent in size to the state of New Jersey 27 Incorporated cities 23 School Districts 4
  • 5. County of Riverside 5
  • 6. Riverside County Substance Abuse Program Since 1992 has received 2/3 of its funding from SAMHSA in the form of a Substance Abuse Prevention and Treatment (SAPT) Block Grant Minimum of 20% of this funding is mandated for prevention strategies Remaining 80% can be spent on either prevention or treatment The amount of treatment dollars released is proportionately tied to the amount of available prevention dollars actually utilized 6
  • 7. Center for Substance Abuse Prevention (CSAP)Identifies 6 Prevention Strategies – 1993 Information Dissemination Education Problem Identification & Referral Community-Based Processes Alternative Activities Environmental Prevention 7
  • 8. 1994 – Institute of Medicine (IOM)recommends 3 targeted categories ofSubstance Abuse Prevention Populations Universal The general public or a segment of the entire population with average probability of developing a disorder, risk or condition Selected Specific sub-populations whose risk of a disorder is significantly higher than average, either imminently or over a lifetime, based solely on membership in the sub-population Indicated Identified individuals who have minimal, but detectable signs or symptoms suggesting a disorder 8
  • 9. IOM Populations December 2002 – SAMSHA proposes utilizing these guidelines 2006 – California ADP establishes the Continuum of Services System Re-Engineering (COSSR) Task Force Based on their work, California embraces IOM recommendations at this time 9
  • 10. Strategic Prevention Framework (SPF) In 2005, ADP notified the Substance Abuse Programs in all 58 counties in California regarding SAMHSA’s intent to introduce the use of the SPF Local counties directed to submit their SPF documents for ADP approval by mid-July 2007 This provided an extraordinary opportunity to use the new IOM prevention populations to define who is served. 10
  • 11. Continuum of Services Assessment CLIENT COMMUNITY Selective CENTERED Monit oring 11
  • 12. As a result of the SPF Process Riverside County realized that adequate prevention programs and county and contractor services were in place to meet the needs of the universal and a small segment of the selective populations However, the indicated population was not served - No prevention services were available to meet the needs of individuals caught in the “gap” between prevention and treatment 12
  • 13. Two choices at that time for “gap” individuals Tell them the “good news/bad news” – Good News - that they did not meet the criteria for admission to treatment Bad News – there are no services that we can provide and send them back out to get worse OR, admit them, inappropriately, to a 16-week treatment program. This was most often the case. 13
  • 14. Individual Prevention Services (IPS) Program This conundrum was the impetus for the design of Riverside County’s Individual Prevention Services (IPS) program – a program designed to fill the traditional “gap” in services 14
  • 15. IPS Program Challenges The concept presented a set of challenges to the county Operational Challenges Funding Space Staff Programmatic Challenges Separating prevention screening from treatment assessment Development of an evidence based intervention 15
  • 16. Operational Challenges - Funding In 2006, $1.3 million was used to fund services at county clinics and private contractors - This funding provided only information dissemination and community based process SPF process indicated that contractors alone were able to meet needs of county for these two strategies as well as environmental prevention for half the cost (roughly $650,000) The remainder ($650,000) was then available for use for the Individual Prevention Services program NO NEW SOURCES OF FUNDING NECESSARY 16
  • 17. Operational Challenge - Space County of Riverside was currently providing outpatient substance abuse services at 7 clinics throughout the county Clinics were located in geographically appropriate areas Co-location of the Individual Prevention Services (IPS) program at current Substance Abuse Clinics made sense – this was the point of entry for all individuals seeking county substance abuse services Service initially began at 6 clinics. 7th clinic brought on board in 2009. 17
  • 18. County of Riverside Substance Abuse Clinic Locations 18
  • 19. Operational Challenge - Staff Initially, 4 certified Substance Abuse Counselors (Behavioral Health Specialist III) that were currently working at various clinics were assigned to serve as Prevention Specialists (PS) in the IPS Program Selected based on their interest in program and on their merit as personable and successful SA counselors These individuals underwent approximately 40 hours of specialized training in the intervention model (described later) Two PS’s assigned to single clinics; other two served two clinics each 19
  • 20. Programmatic Challenge – Separating Prevention Screening from Treatment Assessment Screening – the process used to determine if education can reverse behavior Assessment – the process used to determine a diagnosis for treatment Idea is to screen all individuals presenting for services that are not mandated for treatment and/or are treatment naive (no previous episode) through Prevention first. Those with previous treatment history or mandated for treatment would bypass the prevention screening. 20
  • 21. Programmatic Challenge Selecting an Evidence-Based Intervention CSAP Strategies of Problem Identification & Referral and Education provide the foundation of the intervention Needed a tool that was not disease focused – needed to be able to quickly identify individual’s strengths and internal and external resources Student Assistance Program (SAP) from Desert Sands Unified School District provided model with over 20 years of proven success – Brief Risk Reduction Interview & Intervention Model (BRRIIM) 21
  • 22. BRRIIM Interview Approximately 90 minutes in duration Utilizes CSAP strategy of Problem Identification and Referral Purpose is to identify those individuals whose negative behavior can be reversed through education Family and significant others are encouraged to participate All ages served – 12 years through seniors citizens 22
  • 23. BRRIIM Goals and Objectives Increase access to prevention by filling the “gap” between prevention and treatment services Serve individuals of any age who are AT RISK of abusing alcohol/drugs Implement a problem identification tool to rapidly assess an individual’s risk level Provide evidence based prevention practices aimed at stemming the progression to substance abuse. Engage the individual’s personal motivation to make positive health choices 23
  • 24. BRRIIM – What is it? A neutral screening process Uses a structured interview format A 3-stage motivational interview that is designed to: 1. Engage and motivate the individual to identify strengths and risks 2. Encourage the individual to identify and use their internal and external resources 3. Create a personalized prevention plan that the individual, their family and PS will support 24
  • 25. BRRIIM – What it IS NOT A questionnaire or quick “screen” An unstructured discussion Focused on only one problem Just a step before automatic referral to treatment An assessment or diagnosis Used for the creation of a Treatment Plan An after-care service 25
  • 26. BRRIIM – Stage 1 - Engage Participant and family are together during this phase PS begins identifying risk and protective factors through use of structured interview Two separate formats: Adolescent and Adult Questions center on school/educational (adolescents) and work history (adults), family dynamics, social/ peer support, and stressors Aim is to identify assets in participant’s life that could help them meet desired goals Family members are asked to leave the interview at the conclusion of Stage 1 26
  • 27. BRRIIM – Stage 2 - Explore Stage 2 focuses on more personal and sensitive issues – drug use history, sexual history, criminal history, anger and other emotional issues and other serious concerns Without family members present, further trust is built between participant and PS PS identifies “stage” participant is in using Stages of Change model PS may use one of the more standard screening instruments – CRAFFT, AUDIT, MAST to assist Family members are asked to rejoin interview at end of Stage 2 27
  • 28. BRRIIM – Stage 3 - Enlist Plan of action is formulated with input from all parties If participant demonstrates excessive risk factors or lack of sufficient assets, PS will recommend referral for a diagnostic assessment with a treatment or mental health professional If participant demonstrates that he would benefit from an educational brief intervention, he is retained in the IPS program and enters into a Prevention Service Agreement (PSA) 28
  • 29. Prevention Service Agreement (PSA) Agreement is reached on the following: What the participant is willing to do What the Prevention Specialist is willing to do That the participant’s family or significant others are willing to do Also PS may make certain recommendations to address areas not covered in PSA Agreement is formalized as a document and signed by all parties. Copies are provided to the participant as well as their family members present At this time, it is determined if further sessions are needed 29
  • 30. PSA – Additional Sessions Content Follow-up sessions use the CSAP Strategy of Education Participant receives information, skill building support, and assistance with linkages to community resources PS continues utilizing MI techniques as well as exercises to address participant’s ambivalence and assist them in moving through Stages of Change PS may also introduce activities drawn from Cognitive Behavioral Therapy (CBT) and Brief Intervention (BI) to address flawed thinking and self-defeating behaviors PS builds heavily on protective factors and assets identified during BRRIIM process 30
  • 31. PSA – Additional Sessions Guidelines Time in program is not prescribed – participant remains until goals are met If first plan (Plan A) does not work, then Plan B, Plan C, etc. are developed “Average” is 3.4 sessions following BRRIIM interview If no progress is made, participant can be referred at any time for a diagnostic assessment by a treatment professional Last face-to-face session is followed up in two weeks by phone call to check on status of participant - Satisfaction survey administered at this time 31
  • 32. Family Sessions Family and Significant others are encouraged to be allies in the prevention process through education They may request their own sessions with Prevention Specialist to facilitate this process Utilizes CSAP strategy of Education No confidential information is shared between family members and participant - focus is totally on education 32
  • 33. Documentation – CalOMS Prevention All services provided are documented in CalOMS Prevention System 3 Separate Programs created Initial BRRIIM interview session Set up as a single service Prevention Service Agreement Sessions Set up as a recurring service Separated by type (adult, adolescent, PC1210) Family Sessions Set up as a recurring service 33
  • 34. ResultsFrom July 2007 through June 2010 Total Interviews – 1970 Prevention Service Agreements – 793 (40.2%) Referrals for diagnostic assessment – 1177 (59.8%) 34
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  • 41. Results During first two years* Average BRRIIM interview was 1.8 hours Average number of follow up sessions = 3.4 Average duration of each follow up session = 1.6 hours * Data not yet available for 2009-2010 41
  • 42. Impact - Fiscal Average cost of 16-week Riverside County outpatient treatment program = $4,800 Average cost of IPS program, based on times reported in previous slide = $1,011 Average savings per individual that goes through IPS program = $3,789 Total cost savings to Riverside County over three years = $3,004,677 (793 IPS agreements x $3,789)* Data based on cost reports from FY07/08 and FY08/09 42
  • 43. Impact - Participants Follow-up Interviews with Participants 95% indicated they would seek prevention services through IPS again if needed 95% indicated they would recommend IPS services to others 43
  • 44. Ongoing Challenges Refinement of the Re-Engineered Continuum of Service Approach Program Fidelity Early Identification for self-referring participants 44
  • 45. Next Steps Evaluation CSAP Service to Science Award Recipient 2010 Grant from California ADP Evaluator selected – process to begin soon Data Collection Review Continue working with ADP to improve confidential tracking of individual service data 45
  • 46. How to bring IPS to your county Program manuals developed Adolescent format Adult format Technical Assistance on BRRIIM Model available through CARS at no charge Technical Assistance on CalOMS Prevention reporting set-up available through Riverside County 46
  • 47. Remember, a mighty oak is nothing more than a little nut that held its ground 47
  • 48. For More InformationWilliam W. Harris (951) 782-2408 wwharris@rcmhd.orgJan Ryan (760) 333-6102 jblakeryan@aol.comRiverside County Mental Health Website 48
  • 49. Questions or Comments?????? 49