Enhance Collaboration Among Medical, Behavioral Health, and Social Services Providers

Introductory Paragraph

Many families have complex needs which challenges the capacity of social service providers within the child welfare system. This points to a need to integrate care among medical, behavioral health, and social service providers. For instance, children affected by trauma and prenatal substance exposure often require interventions and treatment, in addition to substance use and mental health treatment provided to parents. Emphasis on treatment interventions and supports which focus only on children or parents separately, often result in fragmented and uncoordinated care. Collaborative practice provides a wider realm of resources to address the needs of families than is traditionally available through one system. Collaborative practice between the dependency court, child welfare, substance use treatment, and other services systems offers a multitude of practical strategies and solutions to improve outcomes for child welfare in families affected by substance use disorders.

Collaborative policies and practices provide access to family-centered interventions. These address the multiple needs of families and positively influence five core outcomes, or the 5Rs, for families in the child welfare system impacted by substance use disorders:

• Recovery: parental recovery from substance use disorders
• Remain at home: more children remain in the care of parents
• Reunification: increased number and timeliness of parent-child reunification
• Recidivism: decreased incidence of repeat maltreatment
• Re-entry: decrease in number of children re-entering out-of-home care

Key Information

When a parent has a substance use disorder the entire family is impacted. A multi-team and community approach best serves families impacted by substance use disorders. This includes professionals building collaborative relationships and working together across agencies and resources to improve outcomes for families. Models of collaborative intervention vary widely in approach. They include innovative strategies such as:

• Wraparound services
• Development of collaborative structures
• Improved cross-system communication protocols
• Collaborative case management and planning
• Co-location of substance abuse specialists in child welfare offices or dependency courts
• Cross-agency training of staff
• Family drug courts

The Family-Centered Approach

The National Center of Substance Abuse and Child Welfare (NCSACW) promotes a family-centered approach. This assesses the needs and well-being of family members and addresses the family in recovery as a whole system. The family-centered approach provides supportive services such as parenting programs, resources surrounding child development, and therapeutic clinical services. SAMHSA identified the following principles of the family-centered approach within a treatment context, all of which translate directly to fostering collaboration among systems and agencies with harm reduction as well:

• Family-centered treatment is comprehensive. Family-centered treatment includes clinical treatment, clinical support, and community support services addressing substance use, mental health, physical health, and developmental, as well as social, economic, and environmental needs for women and their families.
• Women define their families. Family is inclusive of the supportive network of relatives and others whom the woman identifies as part of her family. Treatment can focus on healthy attachment and relationships between parents and children and on women’s relationships with others. Family-centered treatment helps a family function as a unit.
• Treatment is based on the unique needs and resources of individual families. The goals, interventions, type, length, frequency, location, and method of services vary depending on the strengths and needs of the family members.
• Families are dynamic, and thus treatment must be dynamic. Treatment must be able to address evolving and changing family engagement. Everyone may not participate at the same time, stay the same length of time, or have the same motivations.
• Conflict is inevitable, but resolvable. Multiple crises are the norm, not the exception. Families must juggle conflicting needs and priorities and balance the needs of members.
• Meeting complex family needs requires coordination across systems. Most families with substance use disorders participate in multiple service delivery systems (e.g., child welfare, health, criminal justice, education). Coordination and collaboration prevents conflicting objectives and provides optimal support for family members.
• Substance use disorders are chronic, but treatable. The treatment process is not an event but rather a gradual process that moves individuals and families toward lasting recovery. Treatment includes a broad continuum of programs and strategies designed to address dependence, ameliorate adverse consequences associated with substance use, return bio-psycho-social functioning and reduce/eliminate substance use. Behavioral therapies, motivational enhancements, pharmacological interventions, and case management are common elements of treatment.
• Services must be gender responsive and specific and culturally competent. Services must be grounded in and use the knowledge and skills that fit the background of individuals and families. Gender-responsive services recognize the unique characteristics of women’s initiation of use, effects of use, histories of trauma, co-occurring mental health and physical disorders, and other treatment issues including the primacy, importance, and continuity of relationships in women’s lives. Culturally competent services are embedded in the language, values, and experiences of a client’s culture.
• Family-centered treatment requires an array of staff professionals as well as an environment of mutual respect and shared training. Organizational cultures that encourage learning, a team approach, and consultation are necessary for diverse staff members to work together.
• Safety comes first. Maintaining a safe environment for all family members, in all client families, is essential. Programs must have policies for addressing inappropriate behavior in children, youth, and adults and protecting confidentiality. Maintaining trauma-informed and trauma-sensitive services and treatment milieu is of paramount importance.
• Treatment must support creation of healthy family systems. Healthy family systems include structure, appropriate roles, and good communication that allow the family to function as a unit while concurrently supporting the needs of each individual member.

Relevant Research

• SAMHSA provides a summary of data from NSDUH (National Surveys on Drug Use and Health) through the Center for Behavior Health Statistics and Quality. This report titled, "Children Living with Parents Who Have a Substance Use Disorder," indicates that about 1 in 8 children (8.7 million) aged 17 or younger lived in households with at least one parent who had a substance use disorder in the past year. It documents how the entire family is impacted by substance use disorder.

• SAMHSA has also published a report titled "Family-Centered Treatment for Women With Substance Use Disorder." This report includes an extensive bibliography of relevant research on the topic.

Impactful Federal, State, and Local Policies

In 1997, the Adoption and Safe Families Act (ASFA) was enacted to address child welfare cases which lingered in the court system while parents cycled in and out of treatment. The legislation created a mandate to find effective responses to substance abuse and maltreatment within families. Five national reports followed addressing the co-occurring issues of parental substance abuse and child abuse and neglect. These reports are:

• Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy (Child Welfare League of America, 1998)
• Foster Care: Agencies Face Challenges Securing Stable Homes for Children of Substance Users (U.S. General Accounting Office, September 1998)
• No Safe Haven: Children of Substance-Abusing Parents (The National Center on Addiction and Substance Abuse at Columbia University, 1999)
• Healing the Whole Family: A Look at Family Care Programs (Children’s Defense Fund, 1998)
• Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection (Dept. of Health and Human Services, 1999). This report includes research as well as sources and information surrounding federal, state and local policy and funding.

SAMHSA manages Substance Abuse Prevention and Treatment Block Grant program which promotes a socioecological approach integrating individual, family, and community domains. SAMHSA has published two documents that are useful resources for policy and funding considerations:

• "Funding Family-Centered Treatment for Women."
• "State-Level Policy Advocacy for Children Affected by Parental Substance Use."

Medicaid has benefits which are directed to alcohol and substance use. These include the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) to cover both prevention and treatment services for children and adolescents younger than age 21.

Available Tools & Resources

The Children’s Bureau is an agency within the Administration for Children and Families within the U.S. Department of Health and Human Services. It provides a fact sheet titled "Major Federal Legislation Concerned With Child Protection, Child Welfare, and Adoption."

The Treatment Court Institute is one of the divisions of AllRise, formerly known as the National Association of Drug Court Professionals. It has published "Transitioning to a Family-Centered Approach: Best Practices and Lessons Learned from Three Adult Courts." This includes case studies of adult drug courts which included a family-centered approach to treatment and recovery.

The Primary Care Collaborative (PCC) offers a webinar titled "Assessing the Practice with Patients and Families - Opportunities to Improve Patient and Family-Centered Care

NCSACW provides web-based training resources to help professionals increase their knowledge and skills to work with families affected by substance use disorders. They offer a variety of tools, including:

• The Building Collaborative Capacity Series" gives strategies to states and communities to create cross-systems collaborative teams, communication protocols, and innovative practices. These strategies aim to improve screening, assessment, and engagement to best serve families affected by substance use disorders and child welfare service involvement.
• "Understanding Substance Use Disorder - A Resource Guide for Professionals" provides a fundamental understanding of the substance use treatment and recovery process. It is a technical assistance tool designed to equip professionals who refer parents to substance use treatment. It includes a list of questions which child welfare or court staff can ask treatment providers to begin establishing a collaborative relationship with their treatment agency. Professionals using this tool will be able to make informed referral decisions for services which are a good fit to meet the needs of parents and their families.
• "Disrupting Stigma: How Understanding, Empathy, and Connection Can Improve Outcomes for Families Affected by Substance Use Disorders."
• A Webinar titled "Implementation of Family-Centered Practice in Substance Use Disorder Treatment."

Promising Practices

Oregon. Project Nurture integrates maternity care with substance use treatment and features coordination between the health care and human services sectors. It integrates care and services to improve outcomes for opioid-dependent mothers and their children. Project Nurture is a team-based approach to prenatal and postpartum care which includes prenatal clinician, addictions specialist, mental health support, case management, peer support, and parenting resources. Project Nurture provides extended postpartum support for a full year, with pediatric care integrated with the mother’s care, ongoing addiction support, and peer support for parenting. It has a strong commitment to a planned, coordinated approach to the inpatient maternity stay, with protocols for pain management, DHS and social work involvement, and discharge planning. The model provides pregnant women with services in an environment which patients view as respectful and nonjudgmental.  It is tracking pre-term birth rates and documenting cost savings.