The Comprehensive System Change Initiative (CSCI) offers a collaborative
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CSCI Briefing Paper COMPREHENSIVE SYSTEM CHANGE INITIATIVE
April 2012
Improving Mental Health Services for Juvenile Justice System Involved Youths: The Comprehensive Systems Change Initiative
Overview The Comprehensive System Change Initiative (CSCI) offers a collaborative model to identify youths with mental health needs at the earliest point of juvenile justice system contact and at subsequent decision-making points and to ensure an appropriate systems’ response to these youths. This document provides an overview of the CSCI model and discusses implementation in three pilot counties in Pennsylvania. This includes examples of success from CSCI’s core areas of focus: collaboration, identification (screening and assessment), diversion, treatment, continuity of care and evaluation.
Introduction and Purpose National attention has focuced on the increasing number of youths in juvenile justice systems with mental health treatment needs and the failure of traditional rehabilitative interventions – created to address the predictors of crime producing behaviors and public safety- to appropriately or effectively treat these youths. As systems struggled to respond to the youths it because clear no one single agency can solve the mental health/juvenile justice crisis. CSCI provides a framework for identifying youths with mental health needs in contact with the juvenile justice system, diverting these youths to appropriate services outside of, or from further justice system involvement, and, for those not diverted, providing evidence-based services and continuity of care. CSCI requires collaboration from all relevant youthserving agencies, (e.g., probation, corrections, mental/behavioral health agencies, child welfare, substance abuse services, education and victim advocacy). Family members play a prominent role throughout the collaborative process. CSCI’s multi-system approach is key to ensure that the juvenile justice system, which cannot refuse to serve a youth, does not become the default, or replacement mental health system due to the lack of effective assessment and treatment services. CSCI moves youth-serving systems to work together to provide the best services for youths and promotes development of a continuum of evidence-based mental health services in the community that complements and coordinates with the juvenile justice system. CSCI aims to decrease the number of youths with mental health needs that enter into the juvenile justice system or who become more involved in the system over time rather than returning to the community. The longer-term goals are to reduce recidivism of youths and increase their successful re-entry to society and healthy adult lives. Meanwhile, interim outcomes that emerge from CSCI include: • • • • • • • • •
Creation of a collaborative coordinating body. Use of reliable, validated and cross-system screening and assessment tools. Development and delivery of accessible evidenced-based programs in sufficient capacity to meet needs. Development of interagency agreements. Reduction of juvenile justice involvement by minority youths with mental health needs. Promulgation of policies requiring diversion of appropriate youths into community programs when consistent with preserving public safety. Data collection and analysis that is used to continually improve outcomes for youths. Creation of cost sharing mechanisms to increase capacity and services. Coordinated efforts to ensure smooth transition and reintegration from placements.
COMPHREHENSIVE SYSTEM CHANGE INITIATIVE
The Comprehensive System Change Initiative (CSCI) offers a collaborative model to identify youths with mental health needs at the earliest point of juvenile justice system contact and at subsequent decision-making points and to ensure an appropriate systems’ response to these youths. The Council of Juvenile Correctional Administrators (CJCA), then co-director of the National Center for Mental Health and Juvenile Justice (NCMHJJ), developed the CSCI approach in 2001 to through work with Connecticut, Georgia and Pima County, Arizona. This early work laid the foundation for expansion, and with support a Models for Change grant from the John D. and Catherine T. MacArthur Foundation (Foundation) in 2004, the CSCI model was introduced to three counties in Pennsylvania: Allegheny, Chester and Erie.
Implementation CSCI provides a general blueprint for a coordinated system of mental health services for youths in contact with juvenile justice that is guided by the following principles: • Develop and strengthen collaboration at state and local levels, though creation of a coordinating body with representatives from youth serving systems, government and legal agencies, advocacy organizations, and family members and youths; • Identify youths with mental health needs at all critical intervention points along the juvenile justice continuum through the use of reliable and validated multi-system screening and assessment tools; • Divert those youths identified as needing mental health services from juvenile justice to community mental health programs when consistent with preserving public safety; • Build a continuum of evidence-based mental health services in the community that complements and coordinates with the juvenile justice system – avoid building parallel systems; • Ensure continuity of care, including coordinated reintegration planning and linkages with mental health services in communities; • Create cost sharing mechanisms to increase capacity and services that address the needs of youths with complex needs; and • Ensure data collection and analysis and use the information to improve outcomes for youths.
COMPREHENSIVE SYSTEM CHANGE INITIATIVE
Within this collaborative model a mental health services delivery framework for identifying opportunities for screening, assessment, diversion, treatment and linkages to community services along the juvenile justice processing continuum is presented. The framework below is used by sites over time to identify the agency or agencies responsible for youth at each stage of processing, identify existing processes and services as well as gaps and modify the contents to establish the flow chart for their system:
Initial Contact
Intake
Detention
Trial Disposiiton
Placement
Reintegration
Screening
Assessment
Diversion
Treatment
Continuity of Care
Evaluation
Screening and assessment tools are used identify youth with mental health needs at the various points of juvenile justice processing and to link these youth with the best system response, looking first at diversion, and when not consistent with public safety, to ensure an accessible continuum of effective treatment services. This includes coordinated efforts to ensure continuity of care, so that youth experience smooth transition and reintegration from placements. Finally, evaluation ensures that ongoing feedback in the form of data and outcomes is used to gauge progress and to continue to work toward the ideal system.
COMPREHENSIVE SYSTEM CHANGE INITIATIVE Implementation (cont’d) • • • •
Sites are supported in four primary ways as they work to develop a coordinated system: Funding for a full-time mental health coordinator. A one-day technical assistance (TA) forum that introduces a model concept or practices the site is interested in adapting. Availability of additional TA funds to advance their work. Regular phone contact, bi-annual site visits and an annual all sites forum to create a community of practitioners, linkages to experts and resources, and to offer feedback.
CSCI in Pennsylvania Already recognized as a national leader in juvenile justice, Pennsylvania was positioned for change. CSCI endeavored to enter Pennsylvania in a way that was consistent with the organizational structure that characterized the state, namely a highly decentralized juvenile justice system that combines leadership at the state level and decision-making on behalf of youth at the local level amidst a variety of community-based and residential service providers and some stateoperated facilities. One of the lessons learned over the course of the first three-year CSCI project was that leadership at the ground level was essential to keep the work progressing toward successful and sustainable change. When CSCI was launched in Pennsylvania, the Foundation funded mental health coordinator (MHC) positions in each of the participating counties. The individuals were dedicated to full-time to learning, leading and integrating the components of CSCI into local operations. MHCs were recruited early on, with each situated in different agencies: within the Department of Human Services (DHS) director’s office in Allegheny County; the Juvenile Probation Office in Chester County; and, in Erie County, within a private not-for-profit mental health service provider. Notably, the three MHC positions have continued to be funded beyond the Foundation’s support. A state team was also created to affect statewide issues, to lead with pilot projects aimed at diffusion, and to establish sustainable change. Importantly, the state team ensured alignment of new policies and practices with existing and/or new approaches in the state as well as the Models for Change principles and goals. A key example is Balanced and Restorative Justice (BARJ), the foundation of Pennsylvania’s juvenile justice system rooted in community protection, accountability and competency development. Initial CSCI applications and site visits demonstrated that mental health treatment services for juvenile justice youths were mostly available in out-of-home juvenile justice settings. Where community-based mental health services existed, these were inaccessible to many juvenile justice youths and limited to mostly untested locally developed programs rather than those that are evidence-based.
• • •
At the start of the grant several shared issues and objectives across the sites emerged: To begin screening youths earlier in the juvenile justice processing continuum, beyond the current mental health screening in detention centers and shelters only. To adopt shared screening and assessment tools that fit within existing system resources and are aligned with the state’s developing Medical Assistance realignment initiative. To increase community treatment and services resources for youths in contact with juvenile justice, with a focus on evidence-based programs.
COMPREHENSIVE SYSTEM CHANGE INITIATIVE Examples of CSCI accomplishments within each of the three counties and the state level MH-JJ Workgroup follow.
Allegheny County Allegheny County has a longstanding collaboration between juvenile justice and mental health based in case management services provided at all critical juvenile justice intervention points by a DHS contracted agency. CSCI helped guide the collaboration to identify common goals for increasing the identification of youths with mental health problems and the services available to them. Allegheny County leaders developed a strategic plan that included its approach to identify all youths in the juvenile justice system who have a diagnosable emotional disturbance. The Child Behavior Checklist (CBCL) was selected as the mental health screen after much deliberation due to public defender concerns about self-incrimination. CSCI supported efforts to advance screening by initially funding a full-time screener. Finally, a compromise was agreed upon to voluntarily screen only youths with initial adjudications. Subsequently to this initial compromise, the screening population has continued to expand incrementally. The change was explained by the DHS director of systems integration: “Now, we’re identifying individuals who we otherwise wouldn’t have caught. And that’s important. . . Untreated symptoms of their illness can drive them further into the system.” Allegheny leaders also brought more focus to identifying youths with mental health treatment needs at initial police contact through expansion of Crisis Intervention Training (CIT) for police. An Engagement Center is available for police to bring youths for evaluation and linkage to appropriate services. The goal is to divert youths from juvenile justice processing and over time the center is servicing more youths. In addition to expanding identification of youths with mental health problem, Allegheny County increased the services available and accessible. Multisystemic Therapy (MST) was added to the existing array of mental health services and the county’s CSCI collaborative team meeting spurred Juvenile Probation funding for Multidimensional Treatment Foster Care (MTFC).
Chester County Chester County adopted a research-supported informational assessment tool, a tailored version of the Child and Adolescent Needs and Strengths (CANS) through blended funding. The purpose was to facilitate coordinated case planning with a common communication tool across systems as well as shared web-based data collection and analysis. The MHC’s participation in the county’s budget process with system partners and pursuit of other funding opportunities led to support of three positions dedicated to advancing and sustaining the county’s work: a behavioral health coordinator to lend expertise to navigating the various youth-serving systems, a school liaison to work on behalf of youths in preparation for placements and those returning from placements and a family advocate. Chester County selected the Massachusetts Youth Screening Instrument - Second Version (MAYSI-2), a validated mental health screening tool, to identify youths at probation intake. The MHC described the adoption of the MASYI-2 as:
COMPREHENSIVE SYSTEM CHANGE INITIATIVE “Another means to opening productive dialogue between the Juvenile Probation Officer (JPO) and the youth and between the JPO and the family.” Significantly, use of the North Carolina Assessment of Juvenile Risk of Future Offending Pennsylvania Modification (NCAR-PA), a public safety risk tool, was adopted along with the MAYSI-2, both as part of a separate diversion project funded by the Foundation. This reflects the importance of diverting all low risk youths regardless of their mental health status and incremental increases to the number of youths screened and assessed.
Erie County Erie County’s work serves as a model for embodying the principles of CSCI and practices in alignment with the CSCI framework. The collaborative relationship between the chief of juvenile probation and the MHC, which extends to their respective staff, has bridged the divergence commonly found between mental health and juvenile justice agencies. This new relationship and paradigm shift was verbalized by chief many times as he proudly called the mental health staff working with his office as “part of our staff.” The expansion of a pre-existing collaboration with the Mercyhurst College Civic Institute (Mercyhurst College), which has maintained an active database for tracking youth level outcomes, allowed Erie County to track data on its identification of youths with mental health problems, youths diverted, youths servced and services provided. The county’s mental health-juvenile justice coordination and collaboration was greatly enhanced through creation of the Mental Health/Juvenile Probation Office Weekly Triage Team meetings (Triage). Through Triage, recommendations for assessment and the most appropriate services and treatment options are extended to each critical decision-making point. Opportunities for early identification through Triage at the pre-adjudicatory phase and diversion from court processing increased with utilization of the MAYSI-2 at intake and inclusion of diversion committees at the district magistrate level and peer jury. Notably, the MHC provided consultation to the child welfare system around replicating the Triage process. Erie County youths can now access an array of evidence-based services in the community, including FFT, MST, MST-Problem Sexual Behaviors (PSB), MDTC and Trauma-focused Cognitive Behavioral Therapy. Also, Girls Circle Groups are being co-led by mental health and juvenile probation staff with community youths including those in the reintegration phase. From Jan. 1, 2006 to Dec. 31, 2009, 187 of the 778 youths assessed through Triage were recommended for evidencebased programs. Placement showed an overall declining trend. It is believed that the initiative is a contributing factor but this is unclear.
The State Team The MH/JJ Workgroup, led by the deputy director of the Juvenile Court Judges’ Commission (JCJC) and supported by the state coordinator, a CSCI funded consultant, provided leadership and support for the pilot counties and across the state. The state team modeled the collaborative work launched locally under the CSCI initiative, as demonstrated by its membership and expanded subcommittee structure, both of which are inclusive of multiple youth service system and agency representatives and other key stakeholders. The work of the state team crystallized subsequent to a re-organizing meeting, at which time the committee structure was created with an executive committee and substantive area subcommittees. The state team’s areas of oversight
COMPREHENSIVE SYSTEM CHANGE INITIATIVE and activities then increased to the extent that additional support was needed and the Foundation agreed to fund the parttime state coordinator consultant position. Numerous activities attest to the positive impact that the leadership has had in bringing juvenile justice concerns to the forefront at local and state levels, beginning with endorsement of the created MH/JJ Joint Policy Statement by key leaders, which offers a blueprint for creating a model system, http://www.modelsforchange.net/publications/142. Other state-level activities include: The Family Involvement Subcommittee’s published monograph establishing a statewide evidence-based strategy supporting a family role at youth and policy and planning levels; The MAYSI-2 pilot project primarily at probation intake, with over one-third of Pennsylvania’s counties involved as the end of the CSCI grant neared; Piloting of the Youth Level of Service/Case Management Inventory (YLS/CMI), a public safety risk tool, (and a case management component) that assists in tailoring individual service and supervision plans; Enactment of Act 109 extending self-incrimination protections for youths undergoing behavioral health screening and assessment, fostered by the State MH/JJ Team; Two documents created by the Diversion Subcommittee to support local policy development: “Principles of PreAdjudication Diversion in Pennsylvania” and “Guide to Developing Pre-Adjudication Diversion Policy and Practice;” Diversion projects in Allegheny, Lehigh and Chester Counties that encompass the three primary points of contact for pre-adjudication diversion respectively: police, schools and probation intake; and Creation of the “Evidence-Based Prevention and Intervention Support Center,” to support the development and enhancement of evidence-based and promising programs. Pennsylvania is engaged in new wave of reform, the “Juvenile Justice System Enhancement Strategy,” an outgrowth of the Models for Change work. This is being coordinated by the current chair of the State Team under the auspices of JCJC.
Lessons Learned Overall, the leadership level and intensity of ground level support is critical to ensure ongoing training and strategic plan development that is aligned with CSCI goals. Understanding and commitment to the change effort must be encouraged locally and at the state level and individuals in leadership roles must be supported to direct and guide the reforms amidst the many demands on their time and limited resources. This was recognized and positively addressed with two additional part-time positions, one within Pennsylvania and one at the grant manager level subsequent to the start of the CSCI grant activities. The Pennsylvania experience provided an important opportunity to identify organizational factors that contribute to the MHCs’ level of impact as a change agent. Based on this work, the positioning of the MHCs within the youth-serving systems and their respective organizations was key. Positioning should allow for: • Empowerment as a decision-maker while ensuring a direct coordination role to impact practices at the operational level; • An advocacy stance that is grounded in sound principles and research and continually focused on youths’ needs, while maintaining a collaborative stance; and • Access to resources to ensure a data-driven process to guide the change effort through ongoing analysis and adjustment and to demonstrate success.
COMPREHENSIVE SYSTEM CHANGE INITIATIVE
With the exception of Erie County, which had an existing relationship with Mercyhurst College, documenting changes in practice and especially reflecting these changes in youth level outcome data was a struggle. The contributing factors point to some important considerations: • Ensure the capacity for data collection, analysis and reporting, (e.g., link to university, access/support of information technology department, include funds in grant award.) • Create a mutually agreed database/data collection format from the outset that is consistent with expected CSCI outcomes. • Educate stakeholders regarding the usefulness of data, (e.g., performance improvement, opportunity to share successes, obtain and/or maintain funding, and replication.) Two additional lessons learned that were modeled by Pennsylvania leaders: establish a change process that is both “topdown and bottom up,” and include activities and strategies for sustainability. The state leadership was exemplary in areas including piloting evidence-based interventions and instruments, educating stakeholders about the related statewide activities, maintaining communication between subcommittee members and county team representatives, and advancing a multi-faceted and coordinated statewide planning process. To ensure sustainability of reforms and practices improvements beyond Models for Change, Pennsylvania successfully embedded changes in statute, drafted and formalized memorandums of understanding, published guides and best practice policies, and secured designated “homes” within existing organizations to continue and build upon current activities. The strong partnerships among juvenile justice, mental health and numerous other key agencies, organizations and other stakeholders that have been forged and supported in Pennsylvania also will sustain and continue positive impacts on behalf of youths.
