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Implementing a Family Preservation Services Drug and Alcohol Program In Rural Nevada

Theresa M. Anderson, M.Ed., M.S.
Joy Salmon, Ph.D.
Nevada Division of Child And Family Services
Las Vegas, Nevada

Chris Bitonti, Ph.D.
School of Social Work
University of Nevada, Reno
Reno, Nevada

Abstract This paper presents a description of the Family Preservation Services Drug and Alcohol Program in rural Nevada, which is funded by a National Center on Child Abuse and Neglect Demonstration Project grant. An intensive, home-based services model that serves substance abusing child welfare clients is described. The Project is a collaborative effort involving community health, substance abuse, and child welfare agencies as well as university evaluators. The 17-month grant was awarded in October 1994 and ran through June 1996. Challenges faced in implementing services and noteworthy outcomes are discussed.

In October 1994, Nevada's Division of Child and Family Services received a 17-month service demonstration project grant from the National Center on Child Abuse and Neglect (NCCAN Project) for the addition of family preservation teams specializing in substance abuse issues to three child welfare service sites in rural Nevada. The Project is a collaborative effort involving Division of Child and Family Services, State of Nevada Bureau of Alcohol and Drug Abuse, State of Nevada Bureau of Community Health Nurses, Washoe County Juvenile and Social Services, Washoe County Health District, and the University of Nevada, Reno. This paper presents a description of the NCCAN Project.

Profile of Nevada

Nevada is the Nation's seventh largest state and the fastest growing State in the Nation, increasing in total population from 800,508 in 1980 to 1,463,000 in 1994, a growth rate of 86.5 percent (Nevada Children's Mental Health Plan 1995). Census Bureau statistics indicate that about 66 percent of the State's population live in the Las Vegas area, with an additional 22 percent living 500 miles to the north in the Reno/Carson City area. The remaining 12 percent of the State's population live in about 85 percent of its territory (Commission on Substance Abuse, Education, Prevention, Enforcement and Treatment, 1994-95).

Nevada ranks first in the nation for all age groups in per capita alcohol consumption rate. Nevada is second in the nation in cocaine addiction and wine consumption and leads all Western States in beer consumption. From 1981 through 1986, cirrhosis of the liver deaths ranged from being in 7th to 10th place as the leading cause of death for Nevadans, while substance abuse was ranked as being in 5th to 8th place as the leading cause of death during the same period (Nevada State Bureau of Vital Statistics 1991).

Nevada Child Abuse and Neglect Statistics (1994) notes that in 2,763 substantiated cases, 56.1 percent involved alcohol/drug dependency as a major factor contributing to family stress. This is consistent with the Child Welfare League of America's 1993 study, which indicated that more than 50 percent of Child Protective Services (CPS) cases were related to substance abuse (U.S. Department of Health and Human Services 1994).

Family Preservation Services Specializing in Substance Abuse

Family Preservation Services (FPS) is a program within the Division of Child and Family Services that was initiated in 1988. In 1990, a specialized family preservation team was developed to provide services for children at risk of placement due to their parent's substance abuse. This program, funded by the Nevada Bureau of Alcohol and Drug Abuse, was a collaborative effort between county and State.

The NCCAN Project expands these specialized family preservation services to three additional sites. The sites were chosen based on the lack of home-based substance abuse services, the presence of an existing family preservation program, a willingness to participate in the research component, and site accessibility—that is, located within a reasonable driving distance for the research team.

The Project sites are in rural Nevada, as rural areas have less emergency services available for abuse/neglect victims. Further, children in rural Nevada who are removed from their homes due to abuse or neglect are often placed in out-of-county substitute care due to limited substitute care resources and mental health services in their home counties.

Purpose of the Project

The purpose of the NCCAN Project is to reduce the risk of child abuse/neglect by providing family preservation services to those families with children at imminent risk of out-of-home placement due to parental substance abuse. Services focus on stabilizing the family, assisting the family to acknowledge and address the risks associated with the parent's substance abuse, and linking the family to ongoing community resources. Status- offending adolescents are included as a target population in this Project, as their status-offending behaviors (truancy, incorrigibility, runaway) are frequently related to abuse and neglect. In addition, these behaviors often place the youth at risk of further abuse and neglect.

The NCCAN service population includes families who meet the following criteria: (1) placement is imminent for at least one child in the family and/or (2) risk of continued serious abuse or neglect is high; (3) the safety of the child can be maintained through the use of family preservation services; (4) the family is willing to participate in these services; and (5) abuse and/or neglect in the family is directly linked to the substance abuse of one or more caretakers in the home.

Program Description

Intensive Home-based Services

The family preservation model was selected as the preferred service delivery approach, as it serves families who often cannot or do not access or utilize more traditional models of service. This model incorporates a non-blaming, competency- based, problem-solving philosophy; intensive, individualized, home-based services; family systems and ecological perspectives; and a focus on providing the ancillary services needed to stabilize the family. Development and implementation of the Project's policies and practices are guided by and measured against the principles of empowerment, family-centered practice, skill- and competency-building, and culturally relevant and community-based practices.

Professional/Paraprofessional Teams

The Project funds three professional/paraprofessional teams. Each site is targeted to serve up to 25 families by the end of the grant period. Each professional/paraprofessional team is made up of a master's level clinician and a family services worker. The team combines expertise in clinical and systems issues and knowledge of community resources.

Each team serves four to five families at a time, depending on service needs and travel demands. The team works intensively with families in their homes for up to 60 days, meeting at least twice a week for 2 hours each visit. After the initial assessment period, the team approach allows the clinician and family service worker the flexibility to meet with the family together to accomplish multiple tasks or to meet with the family at different times to pursue different tasks. The objective is to offer individualized services that include crisis intervention, individual and family therapy, substance abuse intervention, advocacy, education and skill-building, concrete services (such as teaching clients how to access and use public transportation, develop a household budget, and plan and prepare meals), and referral and linkage to community services and resources. Staff are responsive to client scheduling needs, meet with referred clients within 24 hours, and are available for crises 24 hours a day.

To support follow-through to referrals and in response to recommendations arising out of previous NCCAN Service Demonstration Project evaluations, the Project added a 120-day followup service component. Followup services are provided by the family service worker and include support and continued linkage to community resources.

Staff Support

Each Project team was integrated into existing family preservation programs at each site. This offers staff members a larger support system, providing both clinical and peer support. It also allows for resource sharing and builds on already established referral routes and community education regarding family preservation services.

Clinical supervision is structured in a team approach, with Project staff and supervisor meeting in team consultation twice a week. Together they assess and develop plans to address the family's needs within the intensive, time-limited context. Families and staff alike benefit from the shared expertise of team members. Team consultation in Nevada's family preservation programs has been effective in supporting the retention of therapists who work with this high-risk, multiproblem, demanding client population.

Nevada's family preservation programs have tended to draw professionals new to the field who are interested in developing their skills in working with families. To encourage the hiring and retention of mental health professionals, the Division of Child and Family Services considers itself to be in partnership with these professionals, offering an intensive and supportive learning environment in exchange for a 2- to 3-year commitment to the program.

Hiring professionals with limited experience to work with families whose children are at high risk of abuse or neglect presents new challenges for ensuring children's safety and the provision of quality services. The Project's team approach, its frequent case consultations, and the ready availability of its supervisors counter the risks of these challenges. In addition, staff are provided with training pertinent to the targeted service population and the model of service.

Collaboration With Community Health Nurses

The health and nutritional issues associated with substance abuse and child abuse/neglect make for a natural partnership between family preservation workers serving substance abusing families and community health nurses. County and State community health agencies provide in-kind services and consultation to NCCAN Project family preservation clients. This includes training and services in health-related issues for high-risk clients, more specifically, medical indicators of child/abuse neglect, normal growth and development, feeding, resources for health care, signs and symptoms of common childhood illness, and communicable disease control.

In addition, at one site the community health agency accepts followup referrals of Project clients should continued in-home, family support services be needed. This partnership supports the provision of more comprehensive and coordinated services for at-risk children.

Research Description

Formative and summative levels of evaluation are carried out by the School of Social Work at the University of Nevada, Reno, the Project's independent evaluator. The three components—implementation, effectiveness, and impact—involve a variety of research methods and data collection strategies. While data analysis will be conducted by the research team, interpretation of findings will involve a collaborative effort among the researchers, Division of Child and Family Services staff, and Project partners. The evaluation report will be completed in 1996.

Project Implementation

The formative component of the evaluation involves two phases. The first phase consists of descriptive-level research aimed at comparing actual project implementation features with predetermined criteria for success. The second phase of formative research consists of qualitative research aimed at illuminating program successes as well as implementation problems and their resolution. A series of focus groups will be conducted 1 year following the grant award at each of the three Project sites. Focus group participants at each site will include service recipients, Project staff, referring workers, and personnel from collaborating and community resource agencies.

Service Effectiveness

This evaluation will include examination of outcomes based on intake, termination, and 6-month followup data on Project cases, as well as a comparison between outcomes at different program sites and between substance-involved families and those from the regular family preservation program.

The effectiveness of Project services will be determined by the following criteria: (1) avoidance of placement (determined 6 months after termination), (2) reduction in the risk of abuse/neglect (measured by the Family Risk Scales), (3) reduction in symptoms of substance abuse in the caretaker(s) (measured by the chemical dependency portion of the Addiction Severity Index), (4) improvement in family functioning (measured by the Family Satisfaction Index), (5) improvement in child behavior symptoms (measured by the Child Behavior Checklist), and (6) effective linking of substance abusing families with appropriate resources in the community for long-term support and assistance. Perception of helpfulness by participating families will be examined through client interviews.

Project Impact

To address the policy and service integration issues of concern to this Project, a key informant study is planned. In-depth interviews will be conducted with line-level Child Protective Services and probation staff, supervisory and management personnel from referring agencies, and directors from among the collaborating community resource agencies.

The in-depth interviews are expected to yield qualitative data concerning: (1) specific agency policy changes related to substance-abusing clients, (2) specific agency procedure changes related to substance-abusing clients, (3) informal policy (e.g., worker practices) related to substance-abusing clients, (4) changes in worker/manager views concerning family preservation activities, (5) changes in efforts to collaborate among agencies concerned with substance-abusing families, and (6) proposed legislation related to substance abusing families and family preservation efforts in the State. Data from family interviews outlined under the service effectiveness component of this evaluation plan will be included in the analysis of the program.

Barriers Encountered and Solutions Implemented

Delay in Startup

Startup was delayed for a number of reasons. Nevada's Legislative Interim Finance Committee must approve acceptance of all grant awards. This committee did not meet until 2 months after the notice of award, preventing timely Project implementation. Further, initial plans to house the Project in existing State facilities became untenable due to changes in the needs of other programs. Therefore, office space had to be found, leases had to be approved by Nevada's Board of Examiners, and equipment had to be located and installed.

Another major contributor to a delayed startup was the difficulty in recruiting and hiring staff. Due to the lack of professionals with the needed expertise in Nevada, it was necessary to conduct a national recruitment. Lack of staff and procedural requirements in the State's Personnel Department delayed the recruitment effort and interview process. Once positions were offered, those moving from other States and Canada required from 4 to 6 weeks to relocate.

To compensate for the delay in startup, the Project applied for and received a 4-month extension, until June 1996.

Low Referrals

Referrals have been lower than anticipated at all sites. Given that this is a new service, client recruitment has required continual distribution of information and reminders to referring workers. In addition, at one site, the Project "competes" for referrals due to the concurrent startup of a drug court for parents who have lost custody of their children because of their substance abuse. Referring workers have difficulty determining which is the more appropriate program for their clients, with decisions often left to the presiding judge, who is understandably an advocate for the court's program.

Strategies used to encourage referrals include weekly flyers, monthly meetings with referral agencies, frequent visits to the offices of referring workers, and monthly client status reports. Project staff actively incorporate the referring workers into the treatment process through frequent consultations and joint client sessions when appropriate. This serves to facilitate teaming across agencies. Education in the identification and treatment of substance abuse is also offered to referral agencies. In addition, to counter referring workers' tendency to view the referral criteria as a barrier, site supervisors have become more inclusionary and flexible in their acceptance of referrals.

Staff Retention

The Project has been hampered by multiple staff turnovers due to the time-limited nature of the funding. As the end of the grant period nears, it has become increasingly difficult to retain, recruit, and hire professional staff. This instability in staffing patterns has placed sites behind in meeting their service goals. Extension of the grant by an additional 4 months has been helpful in the hiring of replacement staff and has given sites the opportunity to serve more clients. Also, in an attempt to meet projected service goals, Project referrals are now being served by both regular Family Preservation Services staff and NCCAN staff.

Data Collection

The Federal grant application time frame (approximately 6 weeks) allowed for little involvement of direct service staff in the conceptualization of the research component. This circumstance proved a barrier to the implementation of the evaluation effort. Outcome instruments were selected with the intent of making them useful for practice. However, early feedback suggests that, at best, staff view the instruments neutrally. At worst, they view them as intrusive and inconsistent with the Project's solution-oriented model. Had existing line and supervisory staff been more actively involved in the process of selecting outcome measures for this project, perhaps instruments could have been located with greater perceived clinical utility, thereby enhancing worker competence and, at the same time, improving the reliability of data collection.

To address these concerns, Project supervisors brainstormed and implemented recommendations to improve data collection. These included immediate feedback on instrument data, development of a script for presenting the research component to clients, regular contact with the evaluator, and involvement of staff in discussions of how the research will be useful to practice.

Conclusions and Recommendations

In their analysis of previously funded NCCAN Service Demonstration Projects, evaluators of the Program Lesson Series (U.S. Department of Health and Human Services, Keys to Success 1995) indicate that a 3-year grant period is an insufficient amount of time "to plan, implement, evaluate and institutionalize projects such as these" (p. 13). Instead, they recommend that service demonstration projects have a 5-year time line. The challenges experienced in Nevada's NCCAN Project lend further support to this recommendation.

Further, in the field of family preservation, where the family-centered, strengths- based paradigm is applied, evaluation approaches must mirror practice to be effective. Adopting an ecological perspective and a competence-based, consumer-oriented research strategy that recognizes the respective research partners as equals appears a potentially useful strategy for breaking down traditional barriers in State agency-university collaborations. Workers should be drawn into the process of defining research objectives as early as possible. Their information needs should be considered throughout the conceptualization and design phases of the project. Whenever possible, outcome instruments selected for use in the study should be useful for practice (Bitonti and Salmon 1996).

Despite the difficulties encountered in sustaining this Project, the Project has several outcomes that are noteworthy.

1. By Project end, 75 families will receive intensive home-based services. While the evaluation that examines the effectiveness of these services is not yet complete, these intensive, home-based services that were previously unavailable have supported families and child welfare workers by providing another avenue to meet the "reasonable efforts" mandate, which attempts to preserve the child's family. As Azzi-Lessing and Olsen (1996) indicate, family-centered, home- based services fill a gap in the continuum of services for substance abuse-affected families in the child welfare system.

2. One of NCCAN's objectives for the Service Demonstration Project was to influence Nevada's planning process for the Family Preservation and Support Program. Project updates were provided at each meeting of the Statewide Steering Committee, which also served as the Project's Advisory Committee. In addition, information from national publications and conferences regarding the needs of this service population and the outcomes of other evaluation efforts were shared. Committee members are aware of the Project's service population, service model, and evaluation efforts. Consequently, the Committee included a longitudinal outcome study of family preservation services in the State's Five-Year Plan.

3. Partnerships fostered by this Project have improved the communications and relationships among the State, county, and community agencies involved. Managers and supervisors are sharing information and initiating new partnerships and projects across discipline and agency, particularly related to the overlap of substance abuse and child welfare services. These include collaborations in grant applications, provision of services, research efforts, and regional trainings.

The gains and lessons learned through the NCCAN Project, though hard won, have strengthened the child welfare service delivery infrastructure in rural Nevada. As these services have left their mark on the communities they serve, it is anticipated these communities will seek resources to fill the void resulting from the termination of the Project.

Acknowledgments

NCCAN Project supervisors, Nancy Sirkin, M.S., and Saul Singer, M.S., surveyed referents of their respective programs and provided a summary and interpretation of the responses.

References

Azzi-Lessing, L. and Olsen, L.J. Substance abuse-affected families in the child welfare system: New challenges, new alliances. Social Work 41(1):15-23, 1996.

Bitonti, C. and Salmon, J. Evaluating family preservation in Nevada: A university-State agency collaboration. Family Preservation Journal, Winter, 1996.

Commission on Substance Abuse, Education, Prevention, Enforcement and Treatment. Beating Drugs: A Workable Plan for Nevada. Progress Report, 1994-95.

Nevada Child Abuse and Neglect Statistics. Las Vegas: State of Nevada Division of Child and Family Services, 1994.

Nevada Children's Mental Health Plan. Las Vegas: State of Nevada Division of Child and Family Services, 1995.

U.S. Department of Health and Human Services. Federal Register 59 (83), May 2, 1994.

U.S. Department of Health and Human Services. Keys to Success: Providing Services to Families With Substance Abuse-Related Child Abuse and Neglect Issues. The Program Lesson Series. U.S. Department of Health and Human Services, 1995.

Last Updated 11-7-02