SF AIIM Higher A Cross Agency, Data Driven Approach To Mobilize Juvenile Justice Involved Youth, Families And Systems Towards Change
SF AIIM Higher: A Cross-Agency, Data- Driven Approach to Mobilize Juvenile Justice- Involved Youth, Families and Systems Towards Change* Emily B. Gerber Sai-Ling Chan-Sew San Francisco Department of Public Health Nathaniel Israel Community Behavioral Health Services Jen Leland Child, Youth & Family System of Care*Any information in this presentation are the views of the authors and do not necessarily represent theviews of the San Francisco Department of Public Health
SF Assess Youth Identify Needs Integrate Information Match to Services Higher A U.S. DOJ-funded partnershipbetween the SF Juvenile Probation Dept. & the Dept. of Public Health’s Child, Youth and Family System of Care
SF AIIM: Year 1 The Problem Model & Goals Outcomes
Problem: An epidemic of untreated mental illness inthe Juvenile Justice System? Across the nation: “Mentally Ill Offenders Strain Juvenile System” ~ New York Times, August 9, 2009 All Males FemalesAny Disorder 70.4 66.8 81.0Anxiety Disorder 34.4 26.4 56.0Mood Disorder 18.3 14.3 29.2Disruptive Disorder 46.5 44.9 51.3Substance Use Disorder 46.2 43.2 55.1Shufelt & Cocozza, 2006
In San Francisco, probation youth with behavioral health needs are a shared challenge Child, Youth and Family System of Care (CYF-SOC) Romney, Turner, Bleecker, Israel & Lipton, 2008
How we view a problem changes what we do Born Bad Born Good Views informed by evidence or prejudice?
A different view: A majority of SF probation youth had received prior treatmentIn 2009-10,61% ofyouthscreenedhad priorcontact withbehavioralhealthservices. Butts, Bazemore, & Meroe, 2010
At detention intake, more prior treatment associated with higher functioning Correlation Between Acuity of Needs at Intake and Total Hours of Services Received in Year Prior to AH Intake (N=38) R=.34, p<.05
Multiple factors drive the different pathways to detention for youth with serious mental illness (SMI)SystemAre needs identified?Who are the decision-makers?High stakes decision-pointsCapacity & CostNeighborhoodGuns-Gangs-DrugsPovertyFamily“He’ll grow out of it”KnowledgeResourcesSchoolTeacher QualityLearning SupportsDisciplinary PoliciesTruancy ResponsePBSYouthStigma - “I’m not crazy”Avoidance - “Problem will go away”Service Access – Safe, convenient, meaningful
SF AIIM Higher A U.S. DOJ-funded partnership An interdisciplinary team located at the Juvenile Justice Center On-site standardized clinical screening/assessment, and data-driven plan development combined with linkage to and engagement in appropriate interventions following discharge Designed to target multiple factors at the individual, program and systems level associated with juvenile justice contact for youth with SMI Based on the National Center for Mental Health and Juvenile Justice’s Blueprint for Change: A Comprehensive Model for the Identification and Treatment of Youth in Contact with the Juvenile Justice System (Skowrya & Cocozza, 2005) and on-the-ground expertise
Integrate justice and behavioral health perspectives Cornerstones of an evidence-based High comprehensive model* Severity High MI High MI 1. Juvenile justice & behavioral health systems Low Risk High Risk should collaborate and communicate at critical intervention points. 2. The behavioral health needs of youth shouldMental be systematically identified at all critical stages of juvenile justice processing.Illness Low MI Low MI 3. The behavioral health needs of youth should Low Risk High Risk be systematically addressed in the dispositional planning process. 4. Youth with behavioral health needs in the Low juvenile justice system should have access to Severity High Severity effective EBPs to meet their needs AND to address their criminogenic risks. Risk to Community Safety *Skowyra & Cocozza, (2007). Blueprint for Change: A Comprehensive Model for the Seriousness of Crime, Disposition, Identification and Treatment of Youth with Mental health Needs in Contact with the Juvenile Type and Length of Placement Justice System, The National Center for Mental Health and Juvenile Justice.
Identify a critical and feasible intervention point
Operationalize Steps and Deliver Probation initiates referral @ critical points: Intake, Detention, Supervision.Build on existing PO presents case.mechanisms. Screen for eligibility. Complete CANS in 72 hours. Review CANS & YASI results & possible interventions. Plan, link, & outreach. Youth & family access and engage in treatment.
Year 1 Goals1. Standardize screening and assessment.2. Share information, structure decision-making and plan collaboratively.3. Mobilize youth and families for change.4. Monitor, feedback, and adjust for individual, program and system level progress.
Most AIIM clients were older, male and African American (N=47) Demographic Characteristics Percent N Age Ages 11-14 30% 14 Ages 15-17 70% 33 Gender Male 64% 30 Female 36% 17 Race/Ethnicity Asian/Pacific Islander 4% 2 Black or African Descent 62% 29 Latino/Hispanic 26% 12 Multiracial 2% 1 White 6% 3
Target eligible population with screening Crisis Assessment Tool-10(CAT-10) Indicators & Action LevelsItems 0 1 2 3 Eligibility 1.SF ResidentSuicide Risk If >“2” = +1 2.Under 19Danger to Others If >“2” = +1 3.Detained for > 72 hours 4.SMIJudgment If >“2” = +1 5.Multiple treatment “failures”Psychosis If >“1” = +1Impulsive/Hyper If >“2” = +1 Recommended Level of Care KeyDepression If >“2” = +1 0-1: No evidence of needs and/orAnxiety* link to outpatient as needed 2-4: Moderate to HighTrauma* Needs/Intensive community services; Complete full CANS & LinkAnger Control If “3” = +1 5-7: Acute/Immediate intervention required; Complete full CANS &Sub Abuse* Stabilize/HospitalizeTotal >”2” = SMI
Provide services to youth with more acute needs
At intake,judgment, danger to others, and anger control were the most prevalent needs (N=47) Items Actionable Needs Suicide Risk 11% Danger to Other 74% Judgment 87% Psychosis 6% Impulsive/Hyperactivity 53% Depression 55% Anxiety* 66% Trauma* 62% Anger Control 73% Substance Abuse* 47%
Most had intensive community treatment prior to detention. Level of Care Prior To Detention (N=47) N=6 N=8 N=14 N=17
Most had not been in treatment for a year or more Time between last session and detention (N=47)
A transparent collaboration tool: CANS Ratings Behavioral/Emotional Needs Life Domain Functioning Risk Behaviors Child Needs Child Strengths Caregiver Needs/Strengths Foster Caregiver Resources and Fit Other Treatment NeedsNone Moderate Severe Profound Act ImmediatelyNo Monitor Actaction
Other clinical concerns emerged with full CANS assessment (N=47) Clinical ConcernBehavioral & Emotional Needs Anger 83% Clinical Concern Anxiety 62% Risks Oppositional 62% Judgment 68% Substance Use 53% Delinquency 64% Depression 51% Danger to Others 57% Hyperactivity/Impulsivity 38% Run 23% Trauma 38% Self Harm 17% Conduct 11% Psychosis 6% Caregiver Context Safety 36%Functioning Supervision 34% School Achievement 75% Resources 23% School Behavior 72% Trauma 23% School Attendance 64% Knowledge 21% Family 64% Living Situation 62% Residential Stability 21% Recreational 45% Mental Illness 19%
Goal 2. Shareinformation, structure decision-making and co-plan.
Probation as partner in structured decision-making every step of the way •Based on Medi-Cal and program requirements for entry into different levels of care. •Considers both the presence of more risky or immediate needs, as well as the breadth of needs •Increasing number and severity of needs mean that the case is more complex, requiring more intensive supports. • Youth with more complex cases are more likely to have multiple co-occurring diagnoses, problems in multiple environments and to have fewer supports. • Recommendations for consideration of a specific level of care are the result of an algorithm that matches client case complexityThese tiers represent the minimum severity needed with the frequency and intensity of supports to consider the use of services at a particular level. most likely to be helpful.As such they do not require that services at that level are provided, rather only that they are considered.
Paradigm shift: From service “pile-on” to matching needs to level of care
Turn CANS Data into Action• Provide brief written summary of results, LOC & menu of services.• Dialogue to offer options and build consensus around plan.• Facilitate referrals and linkages• Follow youth and family through until engagement. “Based on the CANS, the Level of Care determination to best meet the behavioral health needs of this child and family is TIER TWO: INTENSIVE HOME BASED SERVICES. Options include: Seneca Connections, Family Mosaic Project, and MST.”
Identify key strengths to offer activities that foster autonomy, connection, self-regard and safety Useable Strengths Child Family 55% Optimism 53% Talent 53% Interpersonal 49% Religion 47% Well Being 36% Vocational 19% Education 13% Caregiver Involvement 43% Organization 36% Knowledge 32% Residential Stability 30% Resources 28% Supervision 19%
“How to do ‘you’ without getting picked up?” Use strengths as leverage for change•Develop & use skills and competencies•Take on new positive roles and responsibilities•Develop self-efficacy and confidence “C is very interested in employment•Develop and enjoy sense of belonging opportunities. Placement at JVS Pre- employment Program while he improves his school attendance might “incentivize” his overall academic progress. Once stable, he could easily transition into a paid part-time job working in his chosen area, MYEEP Boys and Girls Club or weekend work opportunities with the Giants Stadium.”
Goal 4. Monitor, providefeedback, adjust plan as needed, repeat.
Scaffold progress with multi-level feedbackLevel Tangible Benchmarks OutcomesIndividual Work with AH Follow-up CANS “Makes appointments” Follows the case plan Improved well-being & functioning No new chargesProgram Immediate Access Aggregate CANS Engagement for AH Clients linked to “MST” Provide LOC indicatedSystem More collaboration (1 plan) Reduced recidivism High AH-JPD Agreement Increased Engagement for AH Clients overall and by functioning tier.
When you get decision-makers on thesame page about needs and services… Number of Needs on 3 Relevant CANS Number of Needs on 3 Relevant CANS Domains by Recommended Level of Care Domains by Actual Level of Care (N=44) (N=55) R=.42, p<.001 R=.30, p<.05
Youth are more likely to engage in appropriate services
Future Plans Examine outcomes at 6-month and 1-year as compared to sample of “treatment as usual.” Look for and utilize the bright spots o Develop a decision-making care algorithm that utilizes specific strengths-needs clusters. Improve information sharing to better understand pathways to juvenile justice involvement for youth with SMI and pathways to health and well-being.