INTENSIVE SERVICE MODELS FOR FAMILIES AND YOUTH

FAMILY CRITICAL TIME INTERVENTION(FCTI)

February 9, 2012

Los Angeles, California

Research Scientist, The Nathan S. Kline Institute for Psychiatric ResearchResearch Professor, New York University, Department of Child PsychiatryAsst Professor, New York University, Wagner Graduate School of Public ServicePrincipal, SP3 Innovations

Judith Samuels, PhD

What I will cover:

Original Critical Time Intervention model Family adaptation (FCTI): philosophy FCTI Research How the model works Core Components Other work with CTI

CTI Basics

Time-limited Evidence base Increases continuity of care: from

homeless to housed Flexible to meet varying needs of

heterogeneous population Recovery oriented

Why CTI ???

People in multiple systems, multiple situations, often transitioning From homeless to housing From hospital to home From residential treatment program to

home From prison to community From foster care to independence

What is the critical time?

5

Prevention of Homelessness Among Individuals with Mental

IllnessElie Valencia, JD, MA

Ezra Susser, MD, DrPHAlan Felix, MD

NY Presbyterian HospitalDepartment of Psychiatry

The CTI Clinical Trial (1990-94)

Staying Housed N=2,937

Lipton, F. R., Siegel, C., Hannigan, A., Samuels, J., & Baker, S. (2000). Tenure in supportive housing for homeless persons with severe mental illness. Psychiatric Services 51, 479-486.

Why don’t people “survive?” Multiple complex needs Need for supportive relationships Fragmented service systems Lack of continuity of care

RESULTS Recidivism to:

Homelessness Prison Hospital Substance Abuse

Program/Intervention Process: Critical Time Intervention

Time-limited (9-month) case management

Titrated, 3 stages Focused team approach with aim

of reducing recurrent homelessness

Continuity of care Starts before transition takes place

Program/Intervention Process: Critical Time Intervention

Practices Employed - motivational interviewing - harm reduction

Clinical Interventions Mental Health Treatment Compliance Substance Abuse Services Money Management Prevention of Housing-Related Crises Family Psychoeducation Skills Training

Stages of CTI

Transition Months 1-3 Provide specializedsupport. Implementtransition plan

Try Out Months 4-7 Facilitate and testclient’s problem-solving skills

Transfer of Care Months 8-9 Terminate CTIservices with supportnetwork safely inplace

Flexibility of CTI Model

Designed to meet the individual’s needs. This increases cost-effectiveness and maximizes number of individuals served.

Services may be direct and assertive AND/OR maximize linkage to community resources.

Services aim to increase autonomy, self-care, and recovery.

Family CTI (FCTI) Over-arching Philosophy of Approach

comprehensive assessment of the homeless family, but does not assume the complex psychosocial problems of the family are the cause of homelessness

emphasizes that lack of affordable housing is the most important factor causing family homelessness

in some cases, problems arise out of homelessness and poverty, in other cases they merely co-exist

for some families, psychiatric disorders, substance abuse, and an array of psychosocial stressors may be contributing factors to the family’s homelessness

other economic factors contribute, such as the job market and accessibility of entitlements

once a family becomes homeless, any combination of the areas of need may serve to hinder progress into stable community living

intervention should target those problems and needs of the family that are most closely linked to persistent homelessness.

Figure 5-2. Model Program: Critical Time Intervention with Homeless Families

Program Family Critical Time Intervention model (FCTI). The program is jointly funded by NIMH and the Center for Mental Health Services/Center for Substance Abuse Treatment Homeless Families Program.

Goal To apply effective, time-limited, and intensive intervention strategies to provide mental health and substance abuse treatment, trauma recovery, housing, support, and family preservation services to homeless mothers with mental illnesses and substance use disorders who are caring for their dependent children.

Features The Critical Time Intervention model (CTI) was developed in New York City as a program to increase housing stability for persons with severe mental illnesses and long-term histories of homelessness. Its principle components are rapid placement in transitional housing, fidelity to a Critical Time Intervention CTI model for families (i.e., provision of an intensive, 9-month case management intervention, with mental health and substance use treatments), a focused team approach to service delivery, with the aim of reducing homelessness, and brokering and monitoring the appropriate support arrangements to ensure continuity of care.

Research:Westchester Families First

Randomized trial Family Critical Time Intervention (FCTI) with

rapid re-housing Vs. services/system as usual Baseline interview, 3, 9,15,24 month follow-up

Targets homeless families, singles moms w/mental illness and/or substance abuse

Challenges “housing readiness” criteria RAPID RE-HOUSING Housing is SCATTER SITE

Research:CTI for Homeless Families

Target Population Single Female Headed Households Children Under 18 Literally Homeless Mental Health and/or Substance Abuse

Problem High prevalence of:

Trauma history (abuse, separation) Low education Poor work history Health problems Unstable housing history

Research:CTI for Homeless Families

SAMHSA funding for “parent” study NIMH funding for children study Intervention program funded by State of NY Housing funded by HUD and Westchester County Random assignment:

100 families CTI, 123 families in control group No differences between groups at baseline

Outcomes: CTI families have less time homeless Children have better school and mental health outcomes

Family CTI Features

Strengthens ties to services, family, friends

Provides emotional and practical support Time-limited Limited goals Simple and adaptable Provide STRUCTURE to case management

Stages of Family CTI

0-3 Months: Transition to the Community

4-6 Months: Practicing Phase

7-9 Months: Transfer of Care

Stage 1: Transition to the Community

Much of this work was done in shelter This stage may be longer while securing

housing Intensive, assertive outreach-- Develop linkages to

community resources, evaluate and build living skills This stage is more complex for families as

children’s needs are also addressed Provide direct services when needed\

Psychiatist/psychologist meets weekly with CTI workers and consumers

Visit at least weekly More intensive while in shelter

Stage 2:Practicing Phase

Solidify linkages to community resources This includes schools, TANF workers, food

pantries, religious/spiritual resources Promote independent living skills

Includes family resources assessment and plans

Observe and test current plan Develop long-term plan Less frequent visits, more phone follow-up

Stage 3: Transfer of Care

Fine tuning of linkages

Higher level skills training (employment, education, social skills)

Termination with the client

Diagram of FCTI Model

PHASE 1

PHASE 3

PHASE 2

PRE-FCTI

3 months 3 months3 months

- Screening

- Referral - Engagement

- Intake

-Assessment

- Housing

- In vivo

Assessment

-Intervention

Assessment

-Fine tuning

-Less contact

Guidelines for Effective CommunicationActive & Focused, Supporting & Empathetic, Flexible but

Consistent,Fostering autonomy while remaining available

What Makes FCTI Different?

Highly Structured Model Continuity of assistance

From shelter to housing Focus on Cause of Housing Instability Time limited

Although a safety net is recommended High Level Clinical Support Motivational Interviewing Titrated model – intensity lowered over time CTI is an EBP

MODEL COMPONENT:Continuity of Assistance

From shelter to new home FCTI work begins shelter entry Intake/assessment Building relationship through Motivational

Interviewing Service plan based on mom’s goals Connections to community providers Support during move back to community

MODEL COMPONENT:Intensive Clinical Support

Does not replace case work supervisor Can be part time Supports team Provides indirect and direct care Opportunity for staff to increase

knowledge Can help ensure model fidelity

MODEL COMPONENT:Intensive Time Limited – 9 months

Many case work models are much longer Until family is “ready” Can foster dependence

Many families have more strengths than we think “survival” rate is very high

Allows for more families to be service We stress the time limit from day so

everyone is productive

MODEL COMPONENT:Titrated Model – 3 stages

Allows for uneven case load 12 cases: 4 stage 1, 4 stage 2, 4 stage 3

Forces case worker to move family toward discharge

Forces family to move toward discharge Reinforces strengths Reinforces “housing first” goal

Additional adaptations:

Young Families Model Emphasis on child development, baby care Evaluated in pilot study

Youth Aging Out of Foster Care Longer model Emphasis on life skills

Families leaving residential treatment

And more…

Current dissemination work: US Veterans Administration: homeless

veteran families (SSVF program) NY City: Home to Stay City of Ottawa, Canada UMOM, Arizona

Training Guide: Ready in Summer 2012 Training methods: on-site, distance led

Judith Samuels, PhD

For more information contact me:

jasamuels28@gmail.com

Visit the CTI website:www.criticaltime.org