Gold Award: Integrated Services for Mothers With Dual Diagnoses and Their Children

The Arkansas Center for Addictions Research, Education, and Services—Arkansas CARES—provides integrated interdisciplinary services to low-income mothers with dual diagnoses and their children. The program was established in 1992 by health professionals who were providing outreach education and referral services to prenatal care providers across Arkansas. The program's founders recognized that many pregnant, addicted women were being denied substance abuse treatment. Other addicted mothers were being forced to choose between entering a treatment program and caring for their children, who often have special needs themselves.

Arkansas CARES is the only dual diagnosis program of its kind in Arkansas and one of a slowly growing number of residential rehabilitation programs nationwide that serve both mothers and their children. The program's mission is to decrease maternal substance abuse and promote healthy family outcomes through prevention, treatment, education, research, and advocacy. The program's 95 full- and part-time staff devote their efforts to breaking the intergenerational cycles of addiction, child abuse, domestic violence, poverty, and dependence. Arkansas CARES has served as a groundbreaking model for the substance abuse and mental health care provider communities, which are separately funded and frequently separately operated. The program fulfills an important public health role in Arkansas, where about one in three mothers with children under 18 years of age are in need of substance abuse treatment.

Long-term residential treatment is the primary service mode, and it is provided at two treatment community sites—one in Little Rock and one in North Little Rock—where children of all ages live with their mothers and also receive needed health and mental health care. The two treatment communities can house 32 families at a time and currently serve about 160 families a year. In the past ten years, nearly 1,000 families have received treatment and critical services from Arkansas CARES.

Treatment is based on the empowerment of each woman and child and addresses physical health, including brain health; emotional and psychological health; relationship health; spiritual health; and vocational development. In addition to intensive dual diagnosis treatment, services include maternal and child health care at an on-site clinic, education in parenting and health maintenance, vocational and educational training, and children's mental health services, such as developmental assessments, early intervention, therapeutic school visits, and tutoring.

Arkansas CARES is affiliated with the state's only medical school—the University of Arkansas for Medical Sciences (UAMS). The program was originally administered by the department of obstetrics and gynecology of the College of Medicine, but since 1995 it has been overseen by the college's department of psychiatry. Arkansas CARES was selected as the winner of the 2002 Gold Award in the category of large academically or institutionally sponsored programs. The winner for small, community-based programs is described in a separate article on page 1308. Each winning program will receive a plaque and a $10,000 prize made possible by a grant from Pfizer, Inc., U.S. Pharmaceuticals. The awards will be presented on October 9 during the opening session of the Institute on Psychiatric Services in Chicago.

Clients

Women are referred to Arkansas CARES from the Department of Human Services offices, from probation officers, and from health care providers and community agencies across the state. To be eligible for the program, women must either be pregnant or enter treatment with their children. They are allowed to bring children ages 12 and younger to the Little Rock site and children ages 18 and younger to the North Little Rock site, which makes it possible to fully maintain the family unit. If a mother relapses, her children may continue to receive services.

All the clients of Arkansas CARES have a substance use disorder, and most have a comorbid mental illness, such as depression, schizophrenia, bipolar disorder, or posttraumatic stress disorder. During the program's first decade of operation, clients were primarily low-income African-American women from nonintact families who were addicted to crack cocaine. However, since 2000, these demographic characteristics have changed dramatically because of the state's methamphetamine epidemic. Now the typical client is a 30-year-old Caucasian mother from an intact family who is addicted to methamphetamine and who is a victim of domestic abuse or childhood physical or sexual abuse.

Treatment, services, and staff

Arkansas CARES is accredited as a behavioral health care provider by the Joint Commission on the Accreditation of Healthcare Organizations and is licensed by the state as an alcohol and drug treatment program, a child care center, an early intervention provider, and a provider of Child Health Management Services, a Medicaid program for medically at-risk children. The program has grown from a single treatment community in Little Rock that operated a volunteer nursery to its current full-service status, and it now includes a second treatment community in North Little Rock that opened in 2001. Adult and children's mental health services are provided at both sites. The average length of stay in residential care is four to six months.

In addition to residential care, the program operates an evening outpatient program that serves women who have graduated from the treatment community as well as other women in the community. Child care is also provided while the mothers participate in the outpatient program.

The multidisciplinary staff represent many fields and include pediatricians, family medicine physicians, psychiatrists, nurses, social workers, psychologists, specialists in early childhood special education, alcohol and drug abuse treatment counselors, nutritionists, physical and occupational therapists, speech and language pathologists, and toxicology professionals.

The medical community at the University of Arkansas for Medical Sciences is enthusiastic about Arkansas CARES and sends family and community medicine residents, psychiatry residents (PG2 and PG5 child psychiatry fellows), and selected fourth-year medical students to learn about the integrated biopsychosocial and spiritual approach to treating women with dual diagnoses and their children. The program also has connections with the UAMS Colleges of Public Health, Nursing, and Health-Related Professions and hosts students from other state universities in Arkansas.

The program is organized around six teams, each focusing on a key program aspect: management, clinical and treatment matters, research and evaluation, education, residential support, and operations support. The program continues to be directed by its founder and executive director, Cynthia C. Crone, an advanced-practice nurse who is certified as a pediatric nurse practitioner and has an enduring commitment to public health. Ms. Crone manages the program's day-to-day operations, raises funds, and provides vision and direction to the management team to ensure high-quality care and sound plans for the future. A 13-member foundation board helps sustain the program and give it direction.

The clinical and treatment component is led by the medical director, Linda L. M. Worley, M.D., F.A.P.M., an associate professor of psychiatry in the university's psychiatry department and a board-certified psychiatrist with an addictions subspecialization. Dr. Worley, who joined the team in 2000, successfully changed the program's treatment component, which initially offered psychiatric care on a consultation and referral basis, to a fully integrated substance abuse and mental health treatment program.

The key feature of the program model is a continuum of care that encompasses outreach, residential day treatment that includes family therapy, and aftercare services for mothers and their children. The average length of stay in the treatment community is 4.5 months, and extensive aftercare is provided. Education classes for mothers include parenting classes and supervised mother-child play. Aftercare visits by program staff ensure that mothers continue to apply the skills that they have learned in the program. The program also has a strong case management component that addresses child custody issues and legal, financial, vocational, and housing concerns. At least every 90 days, each family meets with its treatment team to unify the team's overall treatment approach to meet the targeted goals.

Clients attend life-skills training classes. Maternal and child health services include health screenings and prenatal care provided by nursing staff at the on-site clinic. Mental health services for children focus particularly on the care of children who have been affected by their mother's addiction. Services include on-site individual and group psychotherapy. child care, developmental assessments, early intervention, therapeutic school visits, and tutoring.

Participants are encouraged to acquire vocational skills; many clients complete the graduate equivalency diploma (GED) program and participate in computer skills training. Seventy percent of the women who complete the program are employed one year later, compared with 30 percent of the women who dropped out of the program early.

Funding and cost savings

In 1991, Ms. Crone and perinatologist Curtis Lowery, M.D., crafted a grant application to the Center for Substance Abuse Prevention, and the project was funded at $1.8 million as a five-year demonstration program in 1992. Since then Ms. Crone has spearheaded funding efforts to maintain and continue the program when the grant period ended and add new services every year. She has learned to braid funds from various public and private funding sources that pay only for specific components of the program. These sources include the Substance Abuse and Mental Health Services Administration, the Arkansas Bureau of Alcohol and Drug Abuse Prevention, the City of Little Rock, Medicaid, the Arkansas Department of Human Services, community organizations such as the Junior League of Little Rock, businesses such as Bank of America, private foundations such as the Frueauff Foundation and the Robert Wood Johnson Foundation, church groups, and individuals.

In 2001, total revenue from funding sources was $2.7 million. The largest portion of 2001 support—about $1.2 million—was from Medicaid, mostly in the form of fee-for-service payments for mental health services. The Arkansas Department of Human Services, the Arkansas Department of Health, and the City of Little Rock also provided funds. Private donations amounted to $50,000. The budget for fiscal year 2003 is $3.3 million.

Cost studies of substance abuse treatment have shown cost savings ranging from $3 to $12 for every dollar spent on treatment. An evaluation of Arkansas CARES found savings of close to $12 for each mother treated. Researchers have estimated that Arkansas CARES can treat 12 families for what it costs to incarcerate one mother and place three of her children in foster care. The estimated cost for a client with two children who remains in the intensive treatment community from four to five months and receives 12 to 18 months of aftercare services is approximately $19,500.

Effectiveness

One of the six core teams at Arkansas CARES is the evaluation team, which includes Nicola Conners, Ph.D., Leanne Whiteside-Mansell, Ed.D., and Robert Bradley, Ph.D., who have been working together for eight years. The team uses a combination of record reviews, focus groups, standardized instruments, and surveys to assess the extent to which the program is meeting the needs of staff members and clients. The evaluation team monitors effectiveness through an ongoing outcomes evaluation study. A recent study of 72 families, including pregnant and parenting mothers, compared three groups: program graduates, early dropouts, and late dropouts. The women who completed the program showed improvement on several critical measures: employment increased from 7 percent to 48 percent, the proportion of graduates with incomes below the poverty line decreased from 93 percent to 69 percent, and homelessness decreased from 40 percent to 31 percent. Women who completed the program fared better than those who dropped out in important areas: 15 percent of the graduates had relapsed to drug use one year after discharge, compared with 58 percent of both groups of dropouts. At about 12 months after discharge, 29 percent of the graduates were unemployed, compared with 70 percent of the dropouts. Less than 4 percent of women who remained in the program for at least one month had a positive test for illicit drugs or alcohol at the time of delivery, compared with 33 percent of those who dropped out early or did not attend. The rates of preterm births were 7 percent and 40 percent, respectively, and average birth weights were 6.5 and 5.8 pounds.

Advocacy and public education

The staff of Arkansas CARES are committed to sharing their knowledge with other providers, policy makers, the scientific community, and the public. Staff members serve on many community boards and task forces addressing such issues as welfare reform, drug-free schools, and mental health care. In 2000 and 2001 staff members gave 52 presentations at local, state, and regional meetings as well as presentations at national meetings of groups such as the American Association for Addiction Psychiatry and the American Psychiatric Association.

The staff of Arkansas CARES view advocacy as a critical role for the program, and they have actively sought systems change to fund, coordinate, integrate, evaluate, and expand both gender-specific and family-focused services for addicted low-income mothers. For example, in 1997, with the support of the Women's Caucus of the Arkansas General Assembly, Arkansas CARES paved the way for passage for the Family Treatment and Rehabilitation Act for Addicted Mothers and Their Children.

As a result of staff advocacy efforts, the program has been recognized with awards from several organizations, including the Arkansas Nurses Association, the Arkansas Perinatal Association, Black Community Developers, the University of Arkansas Cooperative Extension Service, the City of Little Rock, and others.

Last year, in an interview for a newspaper article about the program, Ms. Crone described the motivation that drives program staff: "I am so convinced that this is how we change society." Arkansas CARES has made important and pioneering efforts in that direction and provides a model for others to follow.

For more information contact Cynthia Crone, APN, at Arkansas CARES, 4301 W. Markham, Slot 711-1, Little Rock, Arkansas 72205; phone 501-661-7983, fax 501-661-7985, e-mail, [email protected].