Getting Juvenile Justice Clients Home: A Primary Care Bridging Service
Timely access to psychiatric evaluation and medication management has long been identified as a barrier to improved functioning for children and adolescents who need psychiatric services. Given that a high percentage of youngsters involved in the juvenile justice system have diagnosable psychiatric disorders, the lack of access to psychiatric care has particular applicability to this population.
The HomeCare Program began in 2003 to facilitate psychiatric care for youths (ages 11–16) in the juvenile justice system who were leaving detention centers. The Department of Psychiatry at the University of Connecticut School of Medicine was awarded a grant to implement these services within the federally qualified health centers (FQHCs) in the state. This initiative exemplifies a partnership between state agencies, a university setting, and community primary care clinics in underserved areas.
The first clinic opened in September 2003. The model, conceptualized as a "bridging service," was developed on the premise that an advanced-practice nurse (APN) and a child psychiatrist would treat children and adolescents in the FQHC system, integrating care with child psychiatric staff in the FQHC environment. In Connecticut, APNs have prescriptive authority requiring a collaborative relationship with a physician. APNs and child psychiatrists conduct evaluations and provide medication management services. Case management is provided by APNs. All referrals of juvenile justice children and adolescents come from probation or parole offices or the child welfare worker. The implicit goal of the HomeCare Program is referral to a longer-term provider.
The program was developed to provide a resource for detention-involved youths who require psychotropic medication as a condition of their release and return to the community. The average length of time from referral to intake is 14 days. Each case is triaged on the basis of acuity. Nearly every referral is accepted; exceptions are psychiatric symptoms requiring a higher level of care or addiction to intravenous substances. The program has received 900 referrals since 2003. About 17% are referred again for services after discharge from HomeCare. If other services do not work out, the clients return.
Over the years, program eligibility has broadened beyond youngsters leaving detention to include any youngster involved with juvenile justice. This includes youths aged 16–18 who are involved with juvenile parole or adult probation and youths dually involved with the child welfare system and juvenile justice.
The program has clinic sites in six Connecticut communities and partners with three FQHC systems. Staffing is provided by four APNs and two child psychiatrists. Although the program was developed to serve a prioritized juvenile justice population with psychiatric needs, primary care clients from the FQHC are also given psychiatric evaluations and medication management services. If HomeCare youngsters request it, long-term care needs can also be met in the FQHC system. At this point, they leave HomeCare, are assigned a therapist in the FQHC system, and are offered a "medical home."
The following case exemplar describes how the program works. A 14-year-old female is discharged from juvenile detention on atomoxetine 100 mg daily. She is referred to the HomeCare Program after her primary care provider requests that a community psychiatric provider evaluate her medication. The primary care pediatrician is willing to prescribe atomoxetine but is concerned that the young woman has more complex psychiatric problems that cannot be handled in primary care. A review of records and a psychiatric evaluation are conducted. The client has been nonadherent to the prescribed medication because of gastric pain but admits that she needs "something to help focus in school." Her medication is changed back to methylphenidate HCl, which she had successfully taken as a younger child. After one month her care is transferred to the pediatrician with the caveat that HomeCare will be backup if there are further psychiatric problems. An in-home therapist continues to provide family interventions.
HomeCare does not provide traditional psychotherapy services; staff members aggressively access other providers in the clinic and community to arrange for these services. The program is strengths based, culturally sensitive, and based on an APN nursing model that emphasizes a partnership with the youngsters and their families seeking services. The collaboration with FQHCs effectively connects juvenile justice clients with their home communities. The program also treats a population of children and adolescents involved in primary care in the FQHC but without juvenile justice involvement.
A program manual is in process, and outcome data around rearrest patterns are being analyzed. As a clinical training site for child psychiatry fellows and master's degree nursing students, the HomeCare Program offers a successful model of collaborative practice between state agencies, FQHCs, and a public university.
