SF AIIM Higher: A Cross-Agency, Data-Driven Approach to Mobilize Juvenile Justice-

Involved Youth, Families and SystemsTowards Change*

Emily B. GerberSai-Ling Chan-SewNathaniel IsraelJen Leland

San Francisco Department of Public HealthCommunity Behavioral Health ServicesChild, 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

SFSFA

HigherHigherA U.S. DOJ-funded partnership

between the SF Juvenile Probation Dept. & the Dept. of PublicHealth’s Child, Youth and Family System of Care

ssess Youth

Identify Needs

Integrate Information

Match to Services

SF AIIM: Year 1

The Problem

Model & Goals

Outcomes

Across the nation:“Mentally Ill Offenders Strain Juvenile System”

~ New York Times, August 9, 2009

AllAll MalesMales FemalesFemales

Any DisorderAny Disorder 70.470.4 66.866.8 81.081.0

Anxiety DisorderAnxiety Disorder 34.434.4 26.426.4 56.056.0

Mood DisorderMood Disorder 18.318.3 14.314.3 29.229.2

Disruptive DisorderDisruptive Disorder 46.546.5 44.944.9 51.351.3

Substance Use DisorderSubstance Use Disorder 46.246.2 43.243.2 55.155.1

Shufelt & Cocozza, 2006

Problem: An epidemic of untreated mental illness inthe Juvenile Justice System?

In San Francisco, probation youth with behavioralhealth needs are a shared challenge

Romney, Turner, Bleecker, Israel & Lipton, 2008

Child, Youth and Family System of Care (CYF-SOC)

How we view a problem changes what we do

Born Bad Born Good

Viewsinformed byevidence orprejudice?

A different view: A majority of SF probationyouth had received prior treatment

Butts, Bazemore, & Meroe, 2010

In 2009-10,61% ofyouthscreenedhad priorcontact withbehavioralhealthservices.

At detention intake, more prior treatment associatedwith higher functioning

R=.34, p<.05

Correlation Between Acuity of Needs at Intake and Total Hours ofServices Received in Year Prior to AH Intake (N=38)

Multiple factors drive the different pathways todetention for youth with serious mental illness (SMI)

SystemAre needs identified?Who are the decision-makers?High stakes decision-pointsCapacity & Cost

YouthStigma - “I’m not crazy”Avoidance - “Problem will go away”Service Access – Safe, convenient, meaningful

SchoolTeacher QualityLearning SupportsDisciplinary PoliciesTruancy ResponsePBS

NeighborhoodGuns-Gangs-DrugsPovertyFamily“He’ll grow out of it”KnowledgeResources

A U.S. DOJ-funded partnership

An interdisciplinary team located at the Juvenile Justice Center

On-site standardized clinical screening/assessment, and data-driven plandevelopment combined with linkage to and engagement in appropriateinterventions following discharge

Designed to target multiple factors at the individual, program and systemslevel associated with juvenile justice contact for youth with SMI

Based on the National Center for Mental Health and Juvenile Justice’sBlueprint for Change: A Comprehensive Model for the Identification andTreatment of Youth in Contact with the Juvenile Justice System (Skowrya &Cocozza, 2005) and on-the-ground expertise

SF AIIM Higher

Integrate justice and behavioral health perspectives

Cornerstones of an evidence-basedcomprehensive model*

1. Juvenile justice & behavioral health systemsshould collaborate and communicate atcritical intervention points.

2. The behavioral health needs of youth shouldbe systematically identified at all criticalstages of juvenile justice processing.

3. The behavioral health needs of youth shouldbe systematically addressed in thedispositional planning process.

4. Youth with behavioral health needs in thejuvenile justice system should have access toeffective EBPs to meet their needs AND toaddress their criminogenic risks.

Mental

Illness

Risk to Community SafetySeriousness of Crime, Disposition,Type and Length of Placement

High MILow Risk

High MIHigh Risk

Low MILow Risk

Low MIHigh Risk

HighSeverity

LowSeverity High

Severity

*Skowyra & Cocozza, (2007). Blueprint for Change: A Comprehensive Model for theIdentification and Treatment of Youth with Mental health Needs in Contact with the JuvenileJustice System, The National Center for Mental Health and Juvenile Justice.

Identify a critical and feasibleintervention point

Operationalize Steps and Deliver

PO presents case.

Screen for eligibility.

Review CANS & YASI results &possible interventions.

Plan, link, & outreach.

Complete CANS in 72 hours.

Youth & family access and engage in treatment.

Probation initiates referral @ criticalpoints: Intake, Detention, Supervision.

Build on existingmechanisms.

Year 1 Goals

1. Standardize screening and assessment.

2. Share information, structure decision-makingand plan collaboratively.

3. Mobilize youth and families for change.

4. Monitor, feedback, and adjust for individual,program and system level progress.

Goal 1. Standardize screening andassessment.

Most AIIM clients were older, maleand 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

Eligibility

1.SF Resident2.Under 193.Detained for > 72 hours4.SMI5.Multiple treatment “failures”

Recommended Level of Care Key

0-1: No evidence of needs and/orlink to outpatient as needed2-4: Moderate to HighNeeds/Intensive community services;Complete full CANS & Link5-7: Acute/Immediate interventionrequired; Complete full CANS &Stabilize/Hospitalize

Items 0 1 2 3

Suicide Risk If >“2” = +1

Danger to Others If >“2” = +1

Judgment If >“2” = +1

Psychosis If >“1” = +1

Impulsive/Hyper If >“2” = +1

Depression If >“2” = +1

Anxiety*Trauma*Anger Control If “3” = +1

Sub Abuse*

Total >”2” = SMI

Crisis Assessment Tool-10(CAT-10) Indicators & Action Levels

Provide services to youthwith 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%

N=6

N=14

N=17

N=8

Most had intensive community treatment

prior to detention.Level of Care Prior To Detention (N=47)

Time between last session and detention (N=47)

Most had not been in treatment for a year or more

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 Needs

Moderate

MonitorSevere

ActNone

Noaction

ProfoundAct Immediately

Other clinical concerns emerged withfull CANS assessment (N=47)

Clinical ConcernBehavioral & Emotional Needs

Anger 83%Anxiety 62%Oppositional 62%Substance Use 53%Depression 51%Hyperactivity/Impulsivity 38%Trauma 38%Conduct 11%Psychosis 6%

FunctioningSchool Achievement 75%School Behavior 72%School Attendance 64%Family 64%Living Situation 62%Recreational 45%

Clinical ConcernRisks

Judgment 68%Delinquency 64%Danger to Others 57%Run 23%Self Harm 17%

Caregiver ContextSafety 36%Supervision 34%Resources 23%Trauma 23%Knowledge 21%Residential Stability 21%Mental Illness 19%

Goal 2. Shareinformation, structuredecision-making and

co-plan.

Probation as partner in structured decision-makingevery step of the way

These tiers represent the minimum severity neededto consider the use of services at a particular level.

As such they do not require that services at that levelare provided, rather only that they are considered.

•Based on Medi-Cal and program requirementsfor entry into different levels of care.

•Considers both the presence of more risky orimmediate needs, as well as the breadth ofneeds

•Increasing number and severity of needsmean that the case is more complex, requiringmore intensive supports.

• Youth with more complex cases are morelikely to have multiple co-occurring diagnoses,problems in multiple environments and to havefewer supports.

• Recommendations for consideration of aspecific level of care are the result of analgorithm that matches client case complexitywith the frequency and intensity of supportsmost likely to be helpful.

Paradigm shift: From service “pile-on” tomatching needs to level of care

Turn CANS Data into Action

• Provide brief written summary of results, LOC & menu ofservices.

• 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 ofCare determination to best meetthe behavioral health needs of thischild and family is TIER TWO:INTENSIVE HOME BASEDSERVICES. Options include:Seneca Connections, FamilyMosaic Project, and MST.”

Goal 3:

Mobilize youth and

families for change.

Identify key strengths to offer activities that fosterautonomy, connection, self-regard and safety

Useable StrengthsChild

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

•Develop and enjoy sense of belonging“C is very interested in employmentopportunities. Placement at JVS Pre-employment Program while heimproves his school attendance might“incentivize” his overall academicprogress. Once stable, he could easilytransition into a paid part-time jobworking in his chosen area, MYEEPBoys and Girls Club or weekend workopportunities with the GiantsStadium.”

Goal 4. Monitor, providefeedback, adjust plan as

needed, repeat.

Scaffold progress with multi-level feedback

Level Tangible Benchmarks Outcomes

Individual Work with AH“Makes appointments”Follows the case planImproved well-being & functioningNo new charges

Follow-up CANS

Program Immediate AccessEngagement for AH Clients linked to “MST”Provide LOC indicated

Aggregate CANS

System More collaboration (1 plan)High AH-JPD AgreementEngagement for AH Clients overall and bytier.

Reduced recidivismIncreasedfunctioning

When you get decision-makers on thesame page about needs and services…

Number of Needs on 3 Relevant CANSDomains by Recommended Level of Care

(N=55)

Number of Needs on 3 Relevant CANSDomains by Actual Level of Care (N=44)

R=.42, p<.001 R=.30, p<.05

Youth are more likely to engage inappropriate services

Future Plans

Examine outcomes at 6-month and 1-year ascompared to sample of “treatment as usual.”

Look for and utilize the bright spotso Develop a decision-making care algorithm that utilizes

specific strengths-needs clusters.

Improve information sharing to better understandpathways to juvenile justice involvement for youthwith SMI and pathways to health and well-being.