View from the Middle of the System - College of Continuing...
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View from the Middle of the System–
Indicated Prevention with Adolescents DHCS Substance Use Disorders Conference
Garden Grove CA August 23, 2018
WilliamW.Harris,MPS,CCPS,CADC-IIJanRyan,MA,PPSJimRothblatt,MFT,PPS
SUD Conference Goals 1. Support Coordination and
Integration for SUD Services 2. Explore Opportunities of SUD
Services 3. Focus on What Works to Effect
Change 4. Provide training opportunities
Indicated Prevention with Adolescents: View from the Middle of the System
• …ideal time to undo any perception that substance use and mental health services begin with treatment.
• Indicated prevention providers work one-to-one to strengthen and heal the family and the county system from the middle…
• Listen to and discuss lessons learned from Riverside County…about how to help adolescents and families to navigate the system successfully.
Thinking aloud together about the Continuum of Services
• Where does the Continuum of Services start?
• Does it matter who you ask?
CA. ADP CONTINUUM OF SERVICES
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History of “IOM”• In January 2006, the National Institute of
Medicine (IOM) recommended a Spectrum of Prevention focused on serving the different needs of each of the three categories of prevention population:
1. Universal 2. Selected 3. Indicated - (Individual) Substance Abuse
Prevention addresses the gap between prevention and treatment
Institute of Medicine: definition Indicated Preventive Interventions
Targeted to high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing mental, emotional, or behavioral disorder, or biological markers indicating predisposition for such a disorder, but who do not meet diagnostic levels at the current time.
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Community
Family
School
Individual/Peer
P
Much Commonality in Risk Factors for Behavioral Health Problems
P
P
MuchCommonalityinProtectiveFactorsforBehavioralHealthProblems
Protective Factors
Substance
Abuse
Delinquency
Safe S
exual B
ehavior
School D
rop-O
ut
Violence
Depression &
A
nxiety
Individual
CognitiveCompetence ü ü ü ü ü üEmotionalCompetence ü Social/BehavioralCompetence ü ü ü ü üSelfEfficacy ü BeliefintheFuture ü ü ü ü üSelf-determination ü Pro-socialNorms ü ü ü ü üSpirituality ü ü ü Family, School and Community
OpportunitiesforPositiveSocialInvolvement ü ü RecognitionforPositiveBehavior ü ü ü üBondingtoProsocialOthers ü ü ü ü ü ü
If our theory doesn’t match reality then…
• What have been the consequences so far?
• What happens if Indicated Prevention is marginalized?
• What happens if people think the system begins with treatment?
Brief Risk Reduction Interview and Intervention Model (BRRIIM) =
“prevention conversation” in three stages
Welcome
2.Engage
3.Enlist,Plan
1.Explore
Three-stage BRRIIM Process: Problem Identification and Referral + Education
1. Engage: – Greeting/welcoming to setting, goals;
begin questions to surface strengths, resources, and needs
2. Explore and Energize: – Individual gets time alone with the staff to
identify strengths/needs 3. Enlist and Extend:
– Creating a Prevention Services Agreement
Prevention Services Agreement (PSA) • One person at a time • Customized • Strength-based • CSAP Strategy = Education • Linkages • Coaching • Open door to return for service
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
Basic flow of BRRIIM Process
Referral
BRRIIM Interview: Screening and Brief Intervention
Prevention Agreement Referral to Diagnostic Assessment
Prevention: reverses harmful behavior
No Improvement: referral to assessment
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BRRIIM and Indicated Prevention –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 • Designed to be after-care service
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What makes BRRIIM different
As a model of Indicated Prevention: • Serves the individual and family • Scope is comprehensive, • Opportunity to learn family’s culture • Empowers people to prioritize, create own
prevention plan and outcomes • Keeps door open to return
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Brief
Risk
Red
uction
Int
erview
and
In
terv
ention
Mod
el (BR
RIIM
)
Readiness to Change Summary Table (N=139)
Substance/BehaviorBefore/AfterSession
AverageReadinessRating
AverageChangeRating
%WhoseReadinessIncreased
%ReadyorTryingtoChangeBefore
%ReadyorTryingto
ChangeAfter
Tobacco*(N=31)
Before 3.0+1.6 61% 23% 48%
After 4.6Alcohol*(N=57)
Before 4.5+1.5 61% 47% 84%
After 6.0Marijuana*(N=75)
Before 4.7+1.7 67% 53% 87%
After 6.4RxorOTCDrugMisuse(N=6)
Before 4.7+2.0 67% 50% 83%
After 6.7OtherDrugs*(N=17)
Before 4.1+2.8 71% 41% 88%
After 6.9HarmfulBehavior*(N=66)
Before 4.2+2.3 71% 48% 88%
After 6.5
*Indicates a statistically significant increase in readiness to change (p<0.05).19
SummaryofEvaluationFindingsü Increased protective factors
ü Increased readiness to change AOD-involvement or use
ü Decreased risk factors for developing more serious AOD problems
ü Developed a Prevention Services Agreement
ü Followed a Prevention Services Agreement
ü Identified participants who need to be referred to diagnostic assessment
ü Increased family involvement in participants’ lives
ü Prevented/reduced the onset of participants’ AOD use and related behaviors
ü Increased use of community resources
ü Sustained outcomes resulting from participation in BRRIIM
ü High Levels of Overall Satisfaction
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• “Staying clean has been cool…and I am able to concentrate better at school.”
• “The counseling helped change me. You don’t listen well when it’s your family or friends.”
• “The plan lets you know that someone has faith in you and makes you want to follow through.”
Participant Comments from Pre-Post Survey Findings
Prevention Specialists – View from the Middle?
WhatisaPreventionSpecialistinRiversideCounty?Whataretheylearningabouttheservicesthey
provide,howitfitsintotheContinuumofServices,andhowitischangingthemasproviders.
Indicated Prevention Implementation Challenges
RiversideCountyongoingchallengesandsolutions.
SAPT Funded Primary Prevention
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Information
Dissemination
Education
Alternatives
Problem Identification & Referral
Community-Based Process
Environmental
CSAP strategies for allowable use of SAPT BG funding
7/30/18 25
Primary Prevention Services by Strategy
InformationDissemination,
$10,909,753.00,20%
Education,$7,546,550.00,14%
Alternatives,$6,694,093.00,12%
ProblemIdentificationandReferral,
$849,483.00,2%
Community-BasedProcess,
$18,763,722.00,35%
Environmental,$3,503,175.00,6%
SynarAmendment,$2,000,000.00,4%
ResourceDevelopmentandTechnicalAssistance,
$1,351,442.00,2%
State-levelAdministration,
$2,700,000.00,5%
ExpendituresbyStrategy InformationDissemination
Education Alternatives
ProblemIdentificationandReferral Community-BasedProcess
Environmental SynarAmendment
ResourceDevelopmentandTechnicalAssistance State-levelAdministration
SAPT Primary Prevention -Individuals Served FY 2012-13
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Services by Strategy
Information Dissemination Education
Alternatives
Problem ID and Referral
Community-Based Process Environmental
19059
42309
SAPT Primary Prevention – Individuals Served FY 2012-13
CSAP Strategy Individuals Served in 2012-13 Community-based Processes 42,309 Education 34,919 Information Dissemination 30,764 Alternatives 19,059 Environmental 17,125 Problem ID and Referral 5,257
Based on pie-chart from DHCS 27
IP: amplifies impact of Prevention & Tx
• To identify individuals who are exhibiting early signs of substance abuse and other problem behaviors
• To address risk factors and increase protective factors • To reduce first-time substance abuse and/or to delay
onset of substance abuse • To reduce the length of time the signs and symptoms of
use continue and/or to reduce the severity of substance abuse
• To increase access to prevention and referrals to diagnostic assessment for Tx services
Why IP might be challenging
• History of professional and institutional tension.
• Unintended competition for funds within the prevention field
• Relatively demanding to deliver • IP is a critical discussion between Prevention
and Treatment. Source:TheInstituteofMedicineFrameworkandItsImplicationsfortheAdvancementofPreventionPolicy,Programs,andPracticeByJ.FredSpringerandJoelPhillips
BreakthroughinRiversideCounty
Why IP is a valuable asset for both Prevention and Tx
IP offers the highest probability of getting services to those:
– who will experience the greatest individual harm, and
– create the greatest social harm, as a result of substance abuse.
Source:TheInstituteofMedicineFrameworkandItsImplicationsfortheAdvancementofPreventionPolicy,Programs,andPracticeByJ.FredSpringerandJoelPhillips
Referral Sources for Riverside County Clinics
County Clinics • Self-referral • Substance Use Community Access, Referral, Evaluation,
and Support (SU CARES) line • Clinic Tx. Staff referral • Schools • Family Law • Probation • Senior Programs • Parenting Programs • Dept. of Social Services • Employer
Referral Sources for Schools ü Students who violate a school policy ü When staff worry about their students:
• notices abnormal behaviors or trends • excessive absences • signs of drug or alcohol use • poor hygiene • excessive fatigue/sleepiness
6-PreventionSpecialistFocusGroupFindingsfromKeyEvaluationFindingsofBRRIIMwithintheRCIndividualPreventionServices(IPS)fromShannelleBoyle,Ph.D.
PreventionSpecialistChallenges&Recommendations
PreventionSpecialistFocusGroupFindings#1
Indicator Challenge Recommendation
TimePreventionSpecialistsfeelrushedduetotimeconstraints/treatmentresponsibilities
ReducetreatmentdutiesandincreasetimeallocatedtoBRRIIM
PerceptionsatClinics
Preventionisperceivedas“co-located”attheclinicsratherthananintegralpartoftheclinicsservices
Conductadditionaltrainingdepartment-wideonhowpreventionfitsintotheContinuumofServices
AwarenessaboutBRRIIM
Sometimestherearechallengesreachingalloftheyouthandadultsover55inthecommunitythatcouldbenefitfromBRRIIM
Increaseawarenessthroughacommercial,publicserviceannouncement,video,website,orapp;gettheUnifiedSchoolDistrictandmoreoutsideagenciesonboard
IsolatedatClinics
PreventionSpecialistssometimesfeellonely/isolatedattheclinics
ContinuetoholdMonthlyTrainingsandcoordinatearetreatfortheentireBRRIIMteam
Indicator Challenge Recommendation
BRRIIMInterviewGuide
AcoupleofBRRIIMquestionsarehardforpeopletounderstand;someoftheadolescentquestionswouldbehelpfulforadults;somehavedifficultiestranslatingtheguidefromEnglishtoSpanishduringtheBRRIIMinterview
ReviewtheBRRIIMinterviewguidetoidentifywaystoimproveit(e.g.,rewordquestionsparticipantsdonotunderstand;determinewhichadolescentquestionswouldbeagoodfitfortheadultguide;considerdevelopingaSpanishversion,etc.)
DifficultParents
SometimesPreventionSpecialistsencounterparentswhotrytotakeovertheBRRIIMinterview,makingitchallengingtostayontrack
PreventionSpecialistsshouldbedirectwiththeparentandmakeitclearthattheywanttheyouthtoanswerthequestionsandrepeattheprocessstepssohe/shegetstoalltheinterviewquestions
NoiseandInterruptions
Noisefromotheractivitiesattheclinicandinterruptionssuchasknockingatthedoor,phonecallsandpagesovertheloudspeakerinterferewithBRRIIMsessions
Althoughpreventionhaslittlecontroloverthenoise,andinterruptionissuesvarybyclinic,thePreventionSpecialistscantrytacticssuchasputtingthephoneondivert,placinga“donotdisturb”plaqueontheirdoor,directingstaffnottopagethem,etc.
Self-CareSomePreventionSpecialistsmentionedputtingoffappointmentsandneedingmoretimeforself-care
ThePreventionSpecialistssaidtheywouldlikeadditionalvacationtime
Contact Information William W. Harris, MPS
Riverside University Health System – Behavioral Health Substance Abuse Prevention and Treatment Program
(951) 955-3306
Jim Rothblatt MFT, PPS Prevention Consultant
(760) 534.8340 [email protected]
Jan Ryan, MA, PPS Prevention Consultant
(760) 333-6102 [email protected]
SpecialThankstoRCIPSPreventionSpecialistsandtoourvideospecialistandAdministrativeAssistant:NhanPham
Handouts Provided Online • PowerPoint for this presentation • QuickLook at Brief Risk Reduction Interview
and Intervention Model (BRRIIM) Flow Chart
Pleasecallformoreinformationortoextendthis
discussion.
More Information about School-based Implementations can be found online
• California Department of Education Student Assistance Programs – https://www.cde.ca.gov/ls/he/at/sap.asp
• Murrieta Valley BreakThrough Student Assistance Program video with program overview and interviews with students and parents: https://www.schooltube.com/video/1d2deca67f9b2ee16da7/Breakthrough%20SAP
• Conejo Valley BreakThrough Student Assistance Program: http://www.venturacountylimits.org/en/prevention/school-based-initiatives/breakthrough-student-assistance-program
ManyCaliforniaCountyPreventionCoordinatorsareimplementingIndicatedPreventiontoreachthoseathigherrisk–callformoreinformationandwecanlinkyoutotheirprograms.