Waitemata DHB CADS Pregnancy and Parenting Service (PPS): Outcome Evaluation Report

November 2017

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Table of Contents

Executive summary ................................................................................................... 3

Introduction .............................................................................................................. 5 Background ........................................................................................................................... 5 Evaluation objectives and methods ....................................................................................... 6

Results ...................................................................................................................... 8 Data obtained ....................................................................................................................... 8 Limitations ............................................................................................................................ 8 Overview of PPS Client Demographics ................................................................................... 9 Domain 1. Child health, safety and wellbeing outcomes ...................................................... 11 Domain 2. Unborn children/pregnancy outcomes ............................................................... 17 Domain 3. Client and whānau health, safety and wellbeing outcomes ................................. 19 Other outcomes .................................................................................................................. 22 Other comments ................................................................................................................. 23

Summary................................................................................................................. 25 Conclusion .......................................................................................................................... 26

Appendix 1. Waitlist Management ......................................................................... 28

For further information on this report contact: Marijke Cederman Paula Parsonage Clinical Team Leader Director Pregnancy & Parental Service CADS Waitemata DHB HSD 09 8155830 ext 45123 marijke.cederman@waitematadhb.govt.nz

09 3781843 hsd@xtra.co.nz

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Executive summary Waitemata District Health Board (DHB) Community Alcohol and Drug Service (CADS) provides an Auckland-based outreach Pregnancy and Parenting Service (PPS) for parents of children under the age of three and pregnant women. PPS serves those who are poorly connected to health and social services and who are experiencing multiple and complex problems with issues such as alcohol and other drugs (AOD), family violence, physical and mental health, inadequate housing, poverty and lack of social supports. The key aims of the service are to reduce harm to and improve the wellbeing of children by addressing the needs of their parents and working to strengthen the family environment. PPS targets the critical 0-3-year period of brain development as this is known to significantly impact on multiple areas in children’s lives including future mental and physical health, social and emotional development, behaviour and learning, all of which can relate to potential future problems with employment, offending, and ability to form healthy relationships. PPS adopts a strengths-based approach to assist parents to develop their strengths and overcome vulnerabilities. This evaluation explored outcomes in three key domains: 1) Child health, safety and wellbeing, 2) Unborn children/pregnancy, and 3) Client and whānau health, safety and wellbeing. Data from file reviews, key informant interviews with clients, PPS team and PPS management, and quantitative outcomes data collected routinely by PPS were analysed to assess these outcomes. Where relevant, limitations to the data are noted and discussed in the report. Overall, the data indicate that intended outcomes are achieved for many PPS clients across the three domains. Findings show positive outcomes in relation to providing a safe protective environment for children. Critically, the number of children exposed to violence is reduced. There is evidence of family violence education, referrals to targeted family violence groups, programmes and services, safety planning, practical support in obtaining protection orders and reports of concern made to Ministry of Vulnerable Children Oranga Tamariki. Clients demonstrate increased awareness that violence is unacceptable and increased awareness of the negative impacts of violence on their lives and the lives of their children. Findings suggest that clients develop their understanding of what constitutes safety in relationships and are able to apply this for example, by removing themselves and their children from violent relationships and recognizing risk. Additionally, data indicate that there is a reduction in AOD use and AOD-related harm for PPS clients. Clients frequently attribute their ongoing abstinence or reduction of AOD use (and related harms) to the support received from PPS. Importantly there is a reduction in the number of children exposed to AOD use, consistent with reduced AOD use and also suggesting the PPS ‘safe sober caregiver’ message is effective. Clients describe growth in their understanding of the impact of AOD on their children and on their ability to parent. Clients who are pregnant routinely receive education on risks of AOD use in pregnancy. There is evidence that clients develop positive parenting skills which enable them to better support the health and wellbeing of their children. Many clients highlight this as a key outcome which has a range of impacts, for example enabling them to manage stress, bond with their children, focus and be settled with their children, understand child development

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and respond appropriately to the needs of their children, have custody of their children and ensure the safety of their children. Supporting clients to strengthen their support networks is an important outcome for PPS and data confirm that this outcome is achieved for PPS clients. Findings indicate that clients access supports and services and clients describe knowing how to get help if they need it. For clients who are Māori, this includes developing cultural links, exploring cultural identity and spirituality, strengthening whānau relationships and accessing cultural support. Findings highlight the focus given to developing PPS clients’ confidence, self-efficacy, empowerment, self-determination and self-responsibility. These contribute to the achievement of all outcomes discussed above and set clients up to maintain their gains once discharged from PPS. Accordingly, there is evidence that clients improve their ability to look after themselves and their children and handle life’s ongoing challenges in a healthier way. In particular, several clients talked about their experience in PPS of setting and achieving goals and how valuable this has been for them in giving them agency in their lives. In terms of areas for improvement, findings have highlighted it is not routine for clients who are not pregnant or those on the waitlist to be educated re substance use in pregnancy. There may be further opportunity to systematically provide information on the effects of AOD on unborn children to those on the waitlist via referrers and to consider whether there is a way to provide this information to all PPS clients (whether pregnant or not) without compromising the client-centred and tailored PPS model of service, ie, PPS intentionally focuses on what is important to the client in the context of managing more immediate risk. Another area for improvement relates to data collection. Outcomes relating to immunisation, ECE and receiving Wellchild services were not able to be determined due to problems with the data collection tools (Pre-treatment form and MDT review form). These tools will need to be strengthened or replaced to support ongoing outcomes monitoring. Further, outcomes data on the impact of AOD use on parenting generated via the V-ADOM were not consistent with file and interview data for baseline and reasons for this require further exploration. Overall, the PPS model is effective in achieving intended outcomes, especially in reducing exposure of children to AOD and violence, factors that interfere with optimal brain development for children under 3 years of age. Additionally the service and the approach is highly valued by clients. While it is not possible to solely attribute the achievement of these outcomes directly to PPS intervention, it is notable that many of the outcomes occur subsequent to engagement with PPS and that clients frequently make this attribution. In summary, feedback confirms that PPS provides a highly professional, structured and non-judgmental service to clients, while maintaining an unwavering focus on the safety and wellbeing of children within the context of their family and whānau. Comments from clients and whānau members interviewed for this evaluation universally confirmed this.

In terms of learning from this evaluation it is suggested that PPS continues to maintain the current high quality service delivery model and explores enhancements as follows:

Consider reviewing practices for providing information on the effects of AOD use in pregnancy so that all PPS clients and those on the PPS waitlist who are pregnant have the benefit of this information.

Investigate the issues with the V-ADOM highlighted in this report to better understand its application and utility with this client group/service model.

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Undertake work to strengthen the Pre-treatment and MDT Review forms for the purposes of measuring outcomes in future, or identify other tools better suited to the task.

Introduction Waitemata District Health Board (DHB) Community Alcohol and Drug Service (CADS) provides an Auckland-based outreach Pregnancy and Parenting Service (PPS) for parents of children under the age of three and pregnant women. PPS serves those who are poorly connected to health and social services and who are experiencing multiple and complex problems with issues such as alcohol and other drugs (AOD), family violence, physical and mental health, inadequate housing, poverty and lack of social supports. The key aims are to reduce harm to and improve the wellbeing of children by addressing the needs of their parents and working to strengthen the family environment. PPS is a mobile service covering the resident populations of Waitemata DHB, Auckland DHB and Counties Manukau DHB, approximately 1,415,550 people as at the 2013 Census1. PPS provides case consultation, coordination and case management services. The service has a holistic focus and operates from an assertive outreach approach. CADS has sponsored an independent outcomes evaluation of PPS to determine the extent to which the intended outcomes of PPS have been achieved and to identify areas for service improvement. The evaluation was conducted from May to October 2017.

Background Reducing harm for vulnerable children is a key priority for the New Zealand Government and strongly reflected in the Ministry of Social Development’s White Paper on Vulnerable Children Volumes 1 and 2 and the State Services Commission’s work to deliver Better Public Services Outcomes. The establishment of the Ministry for Vulnerable Children Oranga Tamariki (MVCOT) furthers this agenda. The link between experiences in early childhood and adverse outcomes in adult life such as poor mental health, substance abuse, poor educational outcomes and unemployment are well established and understanding of the associated economic burden is growing (Caspi et al, 2016). Accordingly, there is recognition that providing services to support children early in their lives is a sound approach for improving overall individual, whānau and social outcomes, particularly when such intervention is focused on modifying the child’s environment.2 Based on this, PPS targets the critical 0-3-year period of brain development as this is known to significantly impact on multiple areas in children’s lives including future mental and physical health, social and emotional development, behaviour and learning, all of which can relate to potential future problems with employment, offending, and ability to form healthy relationships. Parental substance use is a recognised risk factor for children, associated with a number of poor health and social outcomes (Ministry of Health, 2015, Ministry of Social Development, 2012). Supporting parents healthy children (Ministry of Health, 2015) guides the mental health and addiction sector to take responsibility for and promote the wellbeing of children,

1http://www.stats.govt.nz/browse_for_stats/population/census_counts/2013CensusUsuallyResidentPopulationC

ounts_HOTP2013Census.aspx 2 See for example: Heckman, J. The Case for Investing in Disadvantaged Children. www.heckmanequation.org

Retrieved February 2015; Campbell F. Conti G. Heckman J. Moon S. Pinto R. Pungello E. Pan Y. 2014. Early Childhood Investments Substantially Boost Adult Health. Science Vol 342: 1478-1485 and Poulton R. The nature of our nurture genes x environment = human behaviour. BPAC 2008 Vol 16: 4-5.

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making the rights and needs of children a core focus. There is a clear expectation that services will take a strengths-based approach to assist parents to develop their own strategies to further develop their strengths and overcome vulnerabilities. The PPS model of service clearly aligns with this approach and has been previously described in detail.3 However, critical aspects of the model, integral to supporting positive outcomes, can be briefly summarized as:

A strengths and empowerment focus, a non-stigmatising approach and a holistic service scope (ie, encompassing multiple complex issues).

Assertive outreach and a mobile team to support accessibility and a strong focus on engagement.

Intensive case management which is open ended, provided to a capped caseload, enabling the client and PPS to work collaboratively on a range of typically long standing issues, to make real gains. This includes a focus on structured goal setting and follow-up.

A robust risk management system combined with a team approach, including multi-disciplinary team (MDT) review and structured risk assessment and management processes undertaken as a team. This is important to contain and support clinicians working with whānau who are experiencing complex issues and often facing significant risk.

Strong effective relationships with other services.

A professional workforce supported by strong leadership and sited within an experienced team of clinicians and peer support workers.

Evaluation objectives and methods

The key objectives of the evaluation were to:

1. Determine the extent to which CADS PPS intended outcomes have been achieved in the following three domains:

o Domain 1. Child health, safety and wellbeing. o Domain 2. Unborn children/pregnancy. o Domain 3. Client and whānau health, safety and wellbeing.

Preliminary analysis was undertaken to identify overarching outcome domains, key outcomes sought for each domain and indicators and measures for each outcome. 2. Identify areas for service improvement to reduce harm and improve the wellbeing of

children.

The analysis covers a three-year period between 01/09/14 and 31/08/17.

A mixed method approach was used including:

Review and analysis of a sample of client files selected at random to provide an in-depth exploration of the client experience from first contact (ie, prior to assessment), outcomes for the client and the nature of the interventions provided by PPS. Ten files were selected per year for each year of the review (01/09/14 - 31/08/15; 01/09/15 - 31/08/16; 01/09/16 - 31/08/17). A Client File Analysis Template was developed to assist with consistent extraction of data relevant to each client’s identified goals and outcomes in relation to the objectives of the evaluation.

3 The PPS model of service has been previously documented in detail, see Parsonage P. (2015). Waitemata DHB

CADS Pregnancy and Parenting Service: Process evaluation. Wellington: Health Promotion Agency.

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Key informant interviews to explore issues relating to client outcomes from client, family and staff perspectives. These included interviews of a sample of PPS clients, PPS team and PPS management team. The sample was purposefully selected according to the following criteria:

o A mix of clients who have been with PPS under 6 months and over 6 months o At least half to be clients who identify as being Māori o 3 - 4 clients who were pregnant on referral o A mix of clients who have custody of children/do not have custody o Geographical spread o 3 - 4 clients who have had peer support with PPS.

Informed consent procedures were followed with all those who elected to participate. A written summary of the interview was provided to each participant to verify accuracy and comprehensiveness. Interview results were analysed for key themes which are summarised in this report.

Analysis of anonymised quantitative data collected routinely by PPS as part of service provision including client demographics and outcomes data.

Client demographic data were generated via CADS patient information management and HCC systems.

Client outcomes data were generated via the PPS Pre-Treatment form, Multi-Disciplinary Team (MDT) Review form and the Visual Alcohol and Drugs Outcome Measure (V-ADOM) collected at time points shown in Table 1 below.

Table 1. PPS Monitoring tools utilised in the evaluation

Tool Assessment @ 4 months* @ 8 months*

Pre-treatment form X

MDT review form X X

Visual ADOM X X X

* Timing is approximate as this varies somewhat from client to client

Information on the nature of these tools and the period for which data were available is outlined below. Note that commencement of the period for which data are available varies according to when the data collection method was introduced.

Pre-treatment form: period collected 15/11/15 – 30/06/17. Pre-treatment (baseline) data are routinely collected by PPS clinicians using a standard Pre-treatment form at the beginning of a client’s engagement with the service. This form has been developed over time by PPS, with the current version having been introduced by 15/11/15. These data provide a baseline of key issues that the client and whānau are experiencing on entry to PPS.

Multi-Disciplinary Team (MDT) review form: period collected 22/02/16 – 30/06/17. MDT review data are routinely collected four months from admission and then every four months during the period the client is engaged with PPS. This form has been developed over time by PPS, with the current version introduced by 22/02/16. These data provide follow up information on key items initially recorded via the Pre-treatment form, thus providing information on behavioural, health and lifestyle changes for the client over time.

V-ADOM form: period collected 15/11/15 – 30/06/17. The Visual-ADOM is a brief questionnaire designed to measure client outcomes at specific points in a client’s recovery journey (Galea & Websdell, 2011). It is derived from the ADOM which was

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developed and validated for use in adult out-patient AOD services in New Zealand (Pulford et al., 2010). The V-ADOM is completed collaboratively by the client and clinician. Data provide information about the client’s status in relation to AOD use, lifestyle, parenting and wellbeing.

Oversight and ethical approval An evaluation steering group provided oversight of the evaluation. Steering group members included representatives of key stakeholders including consumer, Māori, Pasifika, PPS staff and Waitemata DHB clinical and managerial leadership. An evaluation protocol was submitted to the Health and Disability Ethics Committee which formally advised that approval was not required for this evaluation. Approval to proceed was obtained from Waitemata DHB and Auckland DHB Māori Research Committee and Waitemata DHB Research and Knowledge Centre.

Results

Data obtained Data were obtained as follows: 1. A total of 28 client files were accessed and reviewed as follows:

01/09/14 - 31/08/15: 9 files reviewed; 1 file could not be accessed within the evaluation timeframe

01/09/15 - 31/08/16: 10 files reviewed

01/09/16 - 31/08/17: 9 files reviewed; 1 file could not be accessed within the evaluation timeframe.

Files for clients who are Māori comprised 15 of the 28 files, 10 were New Zealand European, and three were files of Pasifika clients, specifically Cook Island Māori, Niuean and Samoan. Twelve of this group had custody of all their children, 12 had custody of some of their children and 4 had custody of none of their children. 17 had received services from PPS for more than one year.

2. A total of 11 key informant interviews were undertaken as follows:

Nine client interviews: 13 participants (one interview included a partner and three interviews included client’s whānau members). All clients were current clients of PPS, with most nearing completion of their treatment.

One interview with PPS team members: ten team members participated, including peer support workers and clinicians from a range of disciplines.

One interview with PPS management team: three participants, including Clinical Team Leader, Clinical Nurse Specialist and Psychiatrist.

3. PPS data, as specified above for the period 15 November 2015 - 30 June 2017 were

provided by Waitemata DHB in Excel spreadsheet format. Data include demographic characteristics and outcomes-related data.

Key findings from all sources are reported below in relation to specified outcomes in each of the three Domains listed above.

Limitations The evaluation relies in part on outcomes data collected by PPS in the course of providing the service ie, via the Pre-treatment form, the MDT review form and the V-ADOM. The V-

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ADOM is a validated outcome measurement tool, however it relies on self-report and is therefore subject to the limitations inherent in self-reporting. In this evaluation V-ADOM data relating to the impact of AOD use on parenting do not reflect what is evident in file review or interviews of PPS clients, the PPS team and the PPS management team (details are provided in the report). Further investigation may assist with understanding the issues surrounding this. The Pre-assessment and the MDT forms are not validated tools and a number of limitations have been found in relation to the validity and reliability of these tools. These limitations are discussed in the body of the report and recommendations have been made in relation to strengthening the tools used by PPS to measure outcomes. PPS is a small service and therefore the overall sample size is unavoidably small, thus limiting the reliability and generalisability of the findings. Adding to this there are missing data, for example, baseline data are not available for all clients and availability of data varies at follow-up points (4 months and 8 months). To mitigate this as far as possible data have been grouped to ensure that baseline/4-month data comprises measures for the same group of clients, and similarly baseline/8-month data. This means that data are excluded for clients for whom there is for no follow-up measure. NB. The findings in this report are based on the data supplied within the evaluation timeframe. In an evaluation such as this there is no scope to include a control group thus limiting the ability to draw firm conclusions regarding the extent to which PPS was instrumental in supporting positive outcomes during the period of treatment ie, other factors which are not accounted for may have been influential. Other limitations are:

Participation in interviews is voluntary and there may be some bias inherent in this self-selection process.

The nature of PPS work is long term and the relatively short time frame for evaluation may limit the opportunity for demonstration of outcomes.

The evaluation is focused on in-treatment outcomes and does not measure outcomes post discharge from PPS.

These limitations are noted and discussed in relevant sections in the report.

Overview of PPS Client Demographics Data pertaining to PPS clients for the period 15 November 2015 - 30 June 2017 (19.5 months)4 provide a snapshot of the clients accessing the service, showing that a total of 116, distinct new clients were admitted to PPS during this period. The majority were female (96%). Most clients predictably fall within 21 - 40-year age range with 57% of clients being 21 - 30 years of age, with a further 34% being aged 31 - 40 years. Five clients (4%) were under 20 years of age and six clients (5%) were aged over 40 years. This is shown in Chart 1 below.

4 Note: this timeframe corresponds to the period for which quantitative outcome data were available.

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Chart 1. % PPS client admissions by age 15 Nov 2015 - 30 June 2017 (n=116)

Of clients newly admitted to PPS during the period 15 November 2015 - 30 June 2017, Māori clients made up 34% of the PPS client group, 45% were New Zealand European/Pakeha, with 10% of clients being Pasifika. The remainder of the PPS client group comprised other European, Indian, Middle Eastern and African. Ethnicity was not specified for one person. These results are shown in Chart 2 below. Chart 2. PPS client admissions by ethnicity 15 Nov 2015 - 30 June 2017 (n=116)

Most PPS clients live in areas with a high deprivation index.5 Within the group of clients newly admitted to PPS during the period 15 November 2015 - 30 June 2017, 73% lived in areas with a decile rating of 6 or greater with 24% living in a decile 10 area (the highest level of deprivation). Data are shown in Chart 3 below.

5 The New Zealand Deprivation Index is a measure of the level of socioeconomic deprivation in small geographic

areas. The index ranges from 1 to 10. A score of 1 indicates that people are living in the least deprived 10 percent (decile) of New Zealand. A score of 10 indicates that people are living in the most deprived 10 percent. Salmond et al. 2007 cited in http://www.odi.govt.nz/resources/research/outcomes-for-disabled-people/nz-dep.html

0%

10%

20%

30%

40%

50%

60%

13-20 yrs 21-30yrs 31-40yrs 41-50yrs

Male

Female

45%

5%

34%

10%

6%

NZ European / Pakeha

Other European

NZ Maori

Pasifika

Other

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Chart 3. % PPS client admissions by deprivation index 15 Nov 2015 - 30 June 2017 (n=116)

Domain 1. Child health, safety and wellbeing outcomes Supporting the health, wellbeing and safety of the children of PPS clients is a primary focus for PPS. The outcomes which PPS seeks to achieve within this Domain include two components:

Child lives in a safe protective environment and

Child’s health and wellbeing needs are met. Each of these is discussed below.

Child lives in a safe protective environment To ensure that children live in a safe and protective environment PPS targets a range of outcomes tailored to clients’ strengths and needs. For this evaluation, the following three key outcomes relating to children’s environments were selected because of their relative importance in relation to the overall child health safety and wellbeing and their measurability:

Child exposure to violence is reduced

Child exposure to alcohol and other drug use is reduced

Child’s (health and wellbeing) needs are met. Child exposure to violence is reduced Data from all sources indicate that exposure to violence for the children of PPS clients reduces during the period of engagement with PPS, details are set out in this section. Exposure to violence is a significant issue for the children of PPS clients. File review data indicate that within the first 4 months of receiving PPS service, violence is identified as a risk factor for a significant proportion of clients (17 of 28 files). File notes make direct reference to both the occurrence of family violence and the risk of recurrence of family violence. Frequently clients’ partners and ex-partners are perpetrating violence, and in a minority of cases (4 of 17) notes refer to violence perpetrated by the client. This indicates a likelihood that children are affected by violence in greater numbers than indicated at the pre-treatment assessment stage as these issues typically take longer to emerge in the treatment arena, as trust is built.

0%

5%

10%

15%

20%

25%

30%

% clients by deprivation index

Clients

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File and interview data indicate that the PPS team has a close focus on positively impacting family violence. For example, there is documented evidence of family violence education (including impact on brain development), referrals to targeted family violence groups, programmes and services, safety planning and evidence of practical support in obtaining protection orders. The following comments from the PPS team also support this:

We’re not a finger wagging service. We’re not judgmental. They learn the impacts of domestic violence and AOD use on their kids and on their lives. They learn parenting skills. Safe sleep. Shaken babies [education on the importance of not shaking babies]. Everyone deserves that information. Our clients don’t know it.

When a client has a new relationship, we are aware of the risks to the children; we have to manage that.

Safer relationships; violence, power and control….some move out of relationships…some push for change. Some relationships change a lot.

We encourage women to value themselves. We validate their experience. Often their partner is doing the opposite – so they get a basis for comparison.

We focus on safety.

Data from client interviews indicate that clients make changes to eliminate or minimise violence in their lives and reduce the exposure of children. Clients spoke directly about violence, the impact on their children, their growing understanding of the impact that exposure to violence has on children and their efforts to change this. The following comments provide examples:

Talking, listening, giving me information, sending me to places… services to help me. Like Breaking the Cycle. CYF said I was mentally ill, but I don’t think that, I think I had battered woman syndrome. PPS helped with education around children being exposed to AOD and to violence. I was in an abusive relationship. I think PPS could see that but they supported me to get out of that at my own pace. They were very much ‘when you’re ready’. I’ve got a protection order now which stipulates complete non-communication with [ex partner]. I have learnt what I need. He had to go. I’m just glad I saw it quicker with him than with my other exes.

Data on exposure of children to family violence were collected at baseline and then again at 4 months for 55 clients.6 These provide a broad indication of positive change for the overall sub-group showing that at baseline 55% of clients’ children were exposed to violence, reducing to 24% at 4 months, while those reporting that children were not exposed to violence increased from 25% at baseline to 44% at four months. It is important to note that there is a large number for whom the outcome was “not known” (31% at baseline, reducing to 22% at four months). Some of these will be clients who do not have custody of their

6 NB. Findings are based on data supplied within the evaluation timeframe. Aggregate data for the group were

provided therefore individual changes are not discernable, however changes for this sub-group as a whole can be seen.

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children, however this figure represents a limitation to this data. Data are shown in Chart 4 below. Chart 4. PPS clients/ children exposed to violence at baseline / 4 months 15 Nov 2015 - 30 June 2017 (n=55)

In comparison data for 39 clients collected at baseline and 8 months show a similar pattern with the number of clients whose children are exposed to violence decreasing. The “not known” group remains fairly constant, as shown in Chart 5 below. Chart 5. PPS clients/ children exposed to violence at baseline / 8 months 15 Nov 2015 - 30 June 2017 (n=39)

Child exposure to AOD is reduced Data from all sources indicate that exposure to AOD is reduced for the children of PPS clients. In PPS, child exposure to AOD includes consideration of the impact of AOD on the client’s ability to provide care for their children in the overall sense (eg emotional engagement, stability, ability to manage daily life etc) and the direct impact of AOD use eg being intoxicated while responsible for the care of children. Details are outlined below.

25%

44%

31%

55%

24% 22%

0%

10%

20%

30%

40%

50%

60%

No Yes Not known

% Children exposed to family violence: baseline/4 months

Baseline 4 months

28%

44%

28%

49%

28%

23%

0%

10%

20%

30%

40%

50%

60%

No Yes Not known

% Children exposed to family violence: baseline / 8 months

Baseline 8 months

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Clients talked about the negative impact of their drug use on their parenting and on their children. They also talked about the gains made in this area since engagement with PPS. The following comments provide examples:

I have been off drugs for 11 months. It’s a long road. I started on drugs when I was 12 and I’m 29 now. I put my habits before my children… PPS have supported me and walked alongside me; keeping me strong in my abstinence and keeping me looking towards the future. They give encouragement to keep doing what I’m doing. Keep on the right track, for me and my family. If I hadn’t got the support from PPS I wouldn’t have my baby and I wouldn’t be off drugs. In your addict life you think you are giving your kids everything. But you don’t give them any time; you don’t have that emotional connection. My kids are happier, they are more confident. There is so much less stress for me.

Data from file review confirms that at assessment and during the period of early engagement with PPS, AOD issues are clearly identified for most PPS clients (26 of 28), including current use of AOD and significant historical issues. AOD use in the context of parenting is noted as a specific risk issue (within the first four months that the client is engaged with PPS) in 13 of the 28 files. Additionally, there is a pervasive theme of AOD use in pregnancy (13 of 28). AOD related risks documented later in a client’s journey with PPS are often noted in the context of relapse and in these situations, there is frequent reference to whether children have been placed at risk. Where clients report that despite relapse a safe sober caregiver has been arranged, PPS verify this with another person in the client’s network such as a family member or on occasion a MVCOT staff member with whom the client is engaged. Providing education on the impact of AOD use on children and the ability to parent effectively is a significant focus for PPS, as highlighted in interviews and evident in file review. PPS team members and management commented that the AOD focus in PPS work is first and foremost the impact on children and ensuring the safety of children. For example:

In PPS substance use is seen in terms of its impact on things eg, impact on children. It is part of the mix of a whole lot of issues. It is high on the list of concerns in the MDTs. Awareness is important. Having a safety plan “Safe sober caregiver” is a key message. It becomes what they do.

Measures collected at baseline and then again at 4 months for 55 clients, indicate positive change for the overall sub-group7 showing that, at baseline, children were exposed to AOD for 55% of clients, reducing to 25% at 4 months, while those reporting that children were not exposed to AOD increased from 20% at baseline to 45% at four months. It is important to note that at baseline exposure to AOD use was not known for 25% of clients and this figure increased at four months to 29%. PPS management team suggested that for some of this group, children have been removed from the care of the client and therefore their circumstances are not known in relation to this variable when the 4-month measure is collected. Additionally on some occasions there will be a discrepancy between what the client reports and what the PPS clinician observes and the clinician will default to “not

7 NB. Findings are based on data supplied within the evaluation timeframe. Aggregate data for the group were

provided therefore individual changes are not discernable, however changes for this sub-group as a whole can be seen.

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known” in the clinical record. The picture is similar for those for whom measures were available at baseline and at 8 months (39 clients) where 59% of clients had children known to be exposed to AOD use at baseline, reducing to 26% at 8 months. These data are shown in Charts 6 and 7 below. Chart 6. PPS clients/ children exposed to AOD at baseline and 4 months 15 Nov 2015 - 30 June 2017 (n=55)

Chart 7. PPS clients/ children exposed to AOD at baseline and 8 months 15 Nov 2015 - 30 June 2017 (n=39)

Child’s (health & wellbeing) needs are met To ensure that childrens’ health and wellbeing needs are met PPS seeks to achieve a range of outcomes. For this evaluation the following four key outcomes were selected because of their relative importance in relation to overall child health and wellbeing and their measurability:

Child is up to date with immunisation

Child regularly attends Early Childhood Education (ECE)

Child is receiving Wellchild services

Client can parent in safe nurturing way.

20%

55%

25%

45%

25% 29%

0%

10%

20%

30%

40%

50%

60%

No Yes Not known

% clients children exposed to AOD use: baseline/4mths

Baseline 4mth

21%

59%

21%

41%

26%

33%

0%

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20%

30%

40%

50%

60%

70%

No Yes Not known

% clients children exposed to AOD use: baseline/8mths

Baseline 8mth

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Data pertaining to immunisation, ECE and Wellchild services are collected via Pre-treatment and MDT forms and were insufficiently reliable to report in this evaluation. Key factors contributing to the limitations include the significant number for whom the data were “not known” which was close to 50% across these outcomes, reported inconsistency in the way the data were collected and lack of sensitivity in the tool. For example, if a client had only one infant in their care then ECE was not appropriate but this was not able to be determined from the data. Results pertaining to ‘Client can parent in safe nurturing way’, are discussed below.

Client can parent in safe nurturing way Ensuring child safety is a key issue of focus for PPS. Indicators of safe, nurturing parenting in this context include such factors as ability to provide children with the basic necessities of life, healthy attachment, understanding and responding to children’s needs in the context of their developmental stage, ensuring children have appropriate health care and educational opportunities and ability to access support and advice, especially in times of particular stress (Note that the latter is discussed in Domain 3 p28). These are areas where many PPS clients are challenged. For example, file review data for the first four months of involvement with PPS shows MVCOT were involved with almost half of the clients (13 of 28) and there are many instances in the files noting that PPS has made a report of concern to MVCOT regarding safety of clients’ children. Appropriately, development of positive parenting skills is a strong focus for both PPS clients and those providing the service. Data from file review and interviews indicate that learning about and developing positive parenting skills is a key outcome for clients. Clients clearly describe the positive outcomes for them in relation to this domain. For example:

My awareness of kids safety is so much stronger. I know now – that’s the important thing. Not what the family say.

There’s less stress. I know what to do now. I don’t need to hit my kids. It’s changed things heaps with my older kids….. It’s much more positive now; talking to them, validating their feelings. Now if they don’t want to talk I leave them, I let them know … come to me when you’re ready. Before I thought they were just being rude.

I have got my bond back with [my older son]. Built my confidence as a dad; given reassurance.

Clients also describe being ‘present’, settled and staying at home as examples of changes they have made, for example:

I stay home. I was never home before…always out. I cook and clean. I’ve grown up. I have a different state of mind, different priorities. I stay at home. I’m settled.

Many clients achieve a goal of participating in parenting education. The Circle of Security programme, provided by PPS and other services, was frequently mentioned by clients as a significant learning process which has impacted on their parenting. The following comments provide some examples:

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I have done some parenting programmes: Mellow parenting and Mums Kitchen Rules. They were good; there were other people wanting the same life as me. I am going to go back.

I did the Circle of Security – so much learning. Learning about my kids, learning about their cues. Learning different perspectives of their behaviour. It’s huge insight. Like what it means when they come to you. I used to think it was attention seeking….get away…but they might just want a hug. Now my relationship with my kids is more about communication, not just telling them what to do.

Data from file review indicate that almost all clients (20 of 28) set and meet goals directly relating to developing positive parenting skills such as managing sleep, breastfeeding, managing behavior and obtaining input for child health issues to name some examples. Many PPS clients have lost one or more children (12 of 28) and frequently for these clients their goals centre on having the opportunity to parent a child and/or to be a parent in some way to their children who are in the custody of others.

Comments from client interviews strongly reinforce this theme. Several clients spoke of the support from PPS in re-gaining and retaining custody and in re-connecting with children in the care of others. For example:

If I hadn’t got the support from PPS I wouldn’t have my baby and I wouldn’t be off drugs. I was pregnant and I was looking for support, because of my lifestyle – I needed support to keep my baby. I needed to tighten up my supports. I started with PPS last year before baby was born. I had to change; I wanted to get CYF off my back. … I wanted to keep my baby; I wanted a better life. PPS are helping us with CYF and our older son.

The PPS team noted that within the context of child safety, which is a paramount focus of the service, the team endeavor to support clients to be effective parents whatever their circumstances. For example:

PPS works with mums regardless of custody arrangements and we advocate for them to be given the opportunity to parent. We give information, sitting with them and their goals. There’s choice. It’s not a one size fits all. Within that the risk to kids is always a consideration. Get them to think about what could happen and educate them on the risks associated with their behaviour and the impact on their kids. We educate on trauma – often they are using because of trauma.

Domain 2. Unborn children/pregnancy outcomes As noted above information from file review indicates that AOD use in pregnancy has occurred for many PPS clients. Supporting clients to have healthy pregnancies and ensuring the health, wellbeing and safety of clients’unborn children are key objectives of PPS. The outcome related to this domain which was selected for evaluation is:

Harm to unborn baby is lessened by abstinence or reduced AOD use.

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Measures selected for this outcome were:

Number of clients engaged in antenatal care

Self-reported levels of AOD use

Evidence of understanding the impact of AOD on unborn children. Data on number of clients engaged in antenatal care was not sufficiently robust to include in this report. The other two outcomes are discussed below.

Self-reported levels of AOD use PPS use the V-ADOM to measure client outcomes related to use of substances, which asks clients to report their use of substances in the past 28 days. Chart 8 below shows mean days of substance use in the last 28 days for the top three drugs of choice (excluding tobacco) for clients during the period 15 November 2015 - 30 June 2017, at baseline and approximately 4-months. Data indicate a trend toward reducing levels of consumption, with the proportion of those reporting no use of substances or substance use 1 - 2 times per month increasing from 53% to 74%. Those who report using most days remains constant at 13%, with those using daily reducing from 8% to 5%. Chart 8. PPS clients V ADOM mean scores top 3 substances baseline / 4 months 15 Nov 2015 - 30 June 2017 (n=62)

Data comparing mean substance use scores at baseline and eight months (available for 36 clients) show a consistent picture. With those reporting no use of substances or substance use 1 - 2 times per month increasing from 47% to 72%, those reporting use most days reducing from 11% to 8% and those using daily reducing from 17% to 11%. This is shown in Chart 9 below.

42%

11%

23% 13%

8% 3%

50%

24%

8% 13%

5% 0%

0%

10%

20%

30%

40%

50%

60%

Never 1-2 t/month 1-2 t/week Most days Daily Not known

V-ADOM mean scores main substances baseline/ 4 months

% baseline % 4 months

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Chart 9. PPS clients V ADOM mean scores top 3 substances baseline / 8 months 15 Nov 2015 - 30 June 2017 (n=36)

Evidence of understanding impact of AOD on unborn children Data from file review and interviews with PPS team and management team indicates that some clients are referred to PPS when pregnant, however because there is a wait time for the service, many have given birth before being engaged with PPS. For example, from file review, 17 of 28 clients were pregnant on referral and of these 10 had given birth at the time of assessment. The wait list is an issue of significant concern for PPS team members and is actively managed to ensure those with highest priority are seen as soon as possible. (See Appendix 1. for detail on criteria applied). Information from files and interviews confirms that PPS liaise with referrers regarding managing risk to children (including unborn children) and clients during the wait time. File review data indicate that for 11 of the 17 clients who were pregnant on referral, concerns regarding AOD use and pregnancy are noted and there is evidence of education on the impact of AOD on the unborn child being provided either directly by PPS or via others involved (eg, midwives, social workers and other AOD treatment providers). No information on this was recorded for the other six clients. From discussion with PPS management it appears that women who are pregnant at the time of assessment (and those who become pregnant while with PPS) are educated re substance use and pregnancy. It is not routine for women who are not pregnant or those on the waitlist to be educated re substance use in pregnancy. The PPS approach is to focus on current risk issues and what is important to the client, for example:

We do the visual ADOM so AOD is always on the radar. What I like about working in AOD is that it’s never about the AOD. We look at the AOD and all the other stuff. We prioritise what is meaningful for them.

Domain 3. Client and whānau health, safety and wellbeing outcomes

Supporting client and whānau health, safety and wellbeing is a focus for PPS. The outcomes which PPS seeks to achieve within this Domain are grouped as follows:

39%

8%

22%

11% 17%

3%

50%

22%

8% 8% 11%

0% 0%

10%

20%

30%

40%

50%

60%

Never 1-2 t/month 1-2 t/week Most days Daily Not known

V-ADOM mean scores main substances baseline/ 8 months

% baseline % 8 months

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Harm associated with client’s substance use is reduced

Client develops and experiences safe relationships

Client has a network of people whom they can call on for support. Each of these is discussed below.

Harm associated with client’s substance use is reduced Data from interviews and file review provide extensive evidence of AOD intervention and support in relation to reducing harm from substance use. As noted above, file review confirms that at assessment and during the period of early engagement AOD issues are clearly identified. There is evidence on all files of AOD education, referral to and liaison with a range of AOD treatment providers and ongoing support given to clients to maintain positive outcomes related to substance use. Clients participate in a range of treatment options typically facilitated by or supported by PPS. As noted above PPS team members highlight that “not one-size fits all” and that “Safe sober caregiver” is a key message and something that PPS monitors closely. PPS management team commented that improvement or remission of substance use disorder is an expected outcome for PPS clients and confirmed that this is high on the list of concerns monitored at MDT meetings. When asked ‘what did you gain from being involved with PPS’ clients often named becoming and remaining alcohol and drug free as a first response. Becoming AOD free or gaining control of AOD use is a significant outcome which clients link to their engagement with PPS. Some clients named this as their key gain and the thing that had made the biggest difference in their life. Several noted that ‘staying stopped’ was a big challenge and that support from PPS was important in helping with this. For example:

Not using alcohol and drugs. That is really the biggie for me. I’ve been two years off them.

They pointed out what was not healthy for me; it was the truth but they put it in a nice way. Getting off the drugs that was the biggest thing for me.

Clients frequently cite changes to AOD as the foundation for re-gaining or maintaining custody of children and for enabling them to make other gains. Non-judgement and effective response to relapse is noted as very helpful to clients in gaining positive outcomes in this area.

I’m struggling with my sobriety. But life is heaps better. People depend on me. I don’t know why I have these lapses to drinking….. they’re getting less, more time in between but I don’t know why I am doing it.

PPS are very supportive if I have a weak moment where it crosses my mind. I can talk to them. They don’t make a big deal about it – different from family and CYFS. But she [PPS clinician] stayed, she didn’t give up. I would phone her, I could tell her when I had relapsed…that was good, it was safety for me.

Data from the V-ADOM relating to the impact of AOD use on parenting does not reflect what is evident in file review or interviews.8 For example, for 102 clients with a baseline V-ADOM

8 The V-ADOM asks clients to report how often (in the past 4 weeks) their alcohol or drug use has caused

problems with paid work, voluntary work, caring for others (such as, looking after children and other family members) or study activities. The response scale is: never, 1/2mth, 1-2wk, most days, daily.

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measure collected within the evaluation timeframe, 82% reported that within the previous 28 days their AOD use had never caused problems with paid work, voluntary work, caring for others (such as, looking after children and other family members) or study activities. The reasons for this result are not known and require ongoing investigation.

Client develops and experiences safe relationships As discussed above, file review data and PPS team and management interviews indicate a focus on impacting family violence and there is significant evidence of education, referrals to targeted groups, programmes and services and evidence of practical support in obtaining protection orders. Client interviews demonstrate increased awareness that violence and related power and control is unacceptable and awareness of the negative impacts of violence on their lives and the lives of their children. Clients describe changes they have made to eliminate violence, anger and unacceptable control by others (as outlined above see pp 11-12). PPS team members highlight a non-judgmental approach, providing information, valuing and validating womens’ experience and helping women to understand the risks, for example:

Learn about relationships – get some insight into risks involved. Our clients have minimised risk in their lives, they learn to view risk differently.

This is reinforced as an effective approach by the clients (see pp 11-12). PPS management team also highlighted the importance of supporting clients to manage anger, for example:

Support / education in how to manage anger - many clients have issues with emotional dis-regulation, poor modelling and limited ability to tolerate distress which is often why they use substances.

Client has a network of people whom they can call on for support Building a sustainable support network is a key outcome that PPS aims to support a client to achieve during their time with the service. File review indicates that clients access support in a range of areas including:

Accessing ongoing AOD-related support of various types tailored to the needs of the client, including Māori rōpū, peer support, 12-step fellowships

Being linked to family violence and parenting services and groups

Being linked with Māori cultural services, supports and groups

Developing stronger family support

Linking to other services including mental health services, physical health services, budgeting services, WINZ and food bank.

Clients describe accessing support and services and knowing how to get help if they need it. For example:

I’ve got access to my CADS counsellor who is happy for me to call when I need to.

At the start it was all about me – it brought out things about me that I didn’t know. I did the “cards” thing9. Now it is more about the community – getting me to look at

9 A tool used by PPS to assist clients to identify their strengths.

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using supports in the community. They have introduced me to play group – it’s good to look at the options; I haven’t taken that up yet.

I have seven children. Some are with family, others are in different places. I have regrets, but I have learnt to handle it now. I have the tools to handle it. I ring my counsellor. Keep busy.

Now that I’m clean I can do more for myself. I don’t like to ask all the time…. but I know they’re there if I need them.

Working to ensure clients are linked to appropriate cultural support is evident in client files, as noted above. Additionally, some of the clients interviewed talked about cultural links and support, all were Māori. Clients described reconnecting with culture and whānau, exploring cultural identity and spirituality and about the importance of this to their recovery. For example:

Reconnecting with Māori culture has been an important part of recovery. I know who I am. There’s so much more to learn. I’m learning to walk not run.

I have a peer support worker as well. I mainly talk with her about reconnecting with my mother and about cultural and spiritual things.

One client said that culture was important to her but indicated that she did not seek support from PPS in this. For example:

Culture is important to me but I do that on my own.

PPS management team commented that the service has worked to broaden the cultural focus and expertise within the system and this remains an area of focus in the service.

Other outcomes Client and PPS team and management interviews highlight the focus given to developing clients’ confidence, self-efficacy, empowerment, self-determination and self-responsibility. These contribute to the achievement of the outcomes discussed above and set clients up to maintain their gains once discharged from PPS. Accordingly, there is evidence that clients improve their ability to look after themselves and their children and handle life’s ongoing challenges in a healthier way. Clients, team members and PPS management all commented on the skills and tools clients gain. PPS team members and management named confidence, self-determination, empowerment and self-responsibility and most agreed that clients are discharged from PPS when they can self-manage and know where to get help if they need it. Comment from the PPS team suggested that there can be differing opinion about the timing of discharge with most indicating that team review processes provide opportunity for discussion and review of the decision to discharge if a client’s circumstances change. Examples of comments include:

We help them [clients] get going then they continue by them-self [themselves].

Handling situations... talking to strangers on the phone.

Self-responsibility – not blaming others; learn to take care of their needs; less reliance on men.

Personal understanding and insight.

They start to manage that stuff on their own.

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Comments from clients strongly reflect these themes. For example, several clients talked about their experience of setting and achieving goals and how valuable this has been for them in giving them agency in their lives. For example:

Helping me figure out the next step. I have achieved goals – positive things.

They help you set goals; strategize around achieving the goals. Sometimes things get pretty busy and I’m not really thinking about my next goal. …

They help you focus and they follow up. The goal setting is so helpful. I think it is really important – taking all the little steps to achieve goals. The goals are always achievable. I’m someone who has good intentions, but having the timeframes – it keeps you moving forward, without knowing it. I love it. I have a box now and the goals go in the box once they have been achieved. They can’t go in the box until they’re done. That’s my system now. I think once I’ve finished with PPS I’ll still do the goal planning. It’s great – you can see how far you’ve come. Trying to take up more of the accountability side for myself now. You set goals on what you want and they help you achieve them. We’re having a break from goals for a little while. Having a rest; some sleep ins.

We always have goals …and we do the goals. PPS helped me make rules for myself – manageable and realistic rules.

Clients also described their developing confidence and skills, for example:

I would always have miscommunication with CYF, then I would get angry. She [PPS clinician] would talk for me. Or we do it together. I can do it myself now. I’ve built up the confidence to talk with CYFs, with my lawyer. I’m stronger, more self-confident. Much more self-empowered. Completely changed. I’m living independently from my parents. I can handle a whole lot more. My next mission is to get my son back. ….. My sister is going to help ….. I will do it, but I need to be ready.

I’ve sorted out one family court situation and I got everything I wanted. One more to go. They helped with some structure - the goals, timeframes to get things done in. It made things manageable - that helped with getting stress levels down. I use the skills.; I get things done now.

Other comments While the evaluation was concerned with outcomes, those interviewed frequently commented on the way in which the PPS service is provided. The themes were highly consistent across client and PPS team and management interviews. Feedback confirms that PPS provides a highly professional, structured and non-judgmental service to clients, while maintaining an unwavering focus on the safety and wellbeing of children within the context of their family and whānau. PPS also provides practical support such as safe sleep capsules,

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contraception, clothing and assistance with driver licensing. Comments from clients and whānau members interviewed for this evaluation universally confirmed this. For example:

You get to know them on a personal level; you can have a laugh with them, but they will always do their job. … They are professional. They [PPS] never left us. She’s very persistent.

They pick up anything that I show interest in and they really follow it through. Lots of things, small stuff like contraception. Anything… They give support. They keep going. They’ve stayed. They’re persistent. I’ve always been able to be open with them. I’ve had the confidence to be open. More so than with the other services I’ve been with. I can be honest. Not sure why…I think it’s a good relationship and they are not judgmental. They never made me feel like I was a lesser person. When someone is a clinician you think they might be a bit ‘judgey’ but they were never like that.

Clients speak very highly of the relationships they build with PPS staff using words like ‘persistent’, ‘gentle’, ‘honest’, ‘genuine’, ‘support’, ‘never give up on me’, ‘always respond’, ‘always there for me’, ‘make it easy’, ‘awesome’ etc.

They are all really nice. [Peer support worker] is really good now for my recovery. She goes to NA with me, comes weekly and just listens to me. It helps that you can relate to them, they’ve been through similar things, they have kids….it’s not just stuff they learned from books. PPS are a guiding hand. They’re a gentle service – I think that’s really good.

They’re the first ones there if things go wrong and its always ‘what can we do?

PPS team commented that home visiting (which is how PPS is delivered) enables clients to access the service as it overcomes barriers such as lack of money, transport and childcare. When asked what they would change about the service, most of the clients interviewed had no recommendations. Two clients described feeling like PPS were ‘pushy’ in the early stages of their engagement and while in hindsight they could understand they both recalled this as a less good thing at the time. A number of clients commented that having a change in PPS clinician had been hard but had been navigated well by the service. All would recommend or have recommended PPS to others, bar one client who commented that she does not make recommendations to other people, despite PPS being a very good service for her.

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Summary

I feel like a burden has gone. Everything is different. They have made a big difference.

Without them I think I would be on the wrong path. It made a big difference. If you met me 2 years ago you would see it; I was all over the place. I kept a lot of things hidden.

As illustrated by the quotes above, notwithstanding the inherent limitations in the data as outlined, findings from this evaluation indicate that intended outcomes are achieved for many PPS clients across the three domains of 1) Child health, safety and wellbeing, 2) Unborn children/pregnancy and 3) Client and whānau health, safety and wellbeing. It is important to be mindful of the limitations of the monitoring tools as highlighted through the evaluation. The Pre-treatment and MDT Review forms need to be strengthened to enable monitoring of key outcomes relating to child health and wellbeing. Alternatively, it may be preferable to identify other tools or methods better suited to the task. Additionally, the issues with the V-ADOM highlighted in this report require further investigation to ensure it is an appropriate tool for use with PPS clients in the context of the PPS model. Domain 1. Child health, safety and wellbeing Findings show positive outcomes in relation to providing a safe protective environment for children. Importantly, data indicate that the number of children exposed to violence is reduced. There is evidence of family violence education, referrals to targeted family violence groups, programmes and services, safety planning, practical support in obtaining protection orders and reports of concern made to MVCOT. Additionally, data show a reduction in the number of children exposed to AOD use. This is consistent with the reported reduction in AOD use and suggests the PPS ‘safe sober caregiver’ message is effective. Clients also describe growth in their understanding of the impact of AOD on their children and on their ability to parent. In relation to child health and well-being, there is evidence that clients develop positive parenting skills. Many clients highlight this as a key outcome for them in relation to a range of factors including managing stress, bonding, being settled, understanding child development, being able to have custody of their children and ensuring safety of their children. Outcomes relating to immunisation, ECE and receiving Wellchild services were not able to be determined due to problems with the data collection tool.

Domain 2. Unborn children/pregnancy Findings from outcome data, file review and interviews indicate that there is a reduction in AOD use for PPS clients. In terms of PPS clients gaining understanding of the impact of AOD on the unborn child, clients who are pregnant receive education on risks of AOD use in pregnancy. It is not routine for women who are not pregnant or those on the waitlist to be educated re substance use in pregnancy as PPS focus on current risks and goals relevant to the client. The wait list is a concern to PPS and is actively managed to ensure those with highest priority, such as pregnant women, are seen as soon as possible. PPS liaise with referrers regarding managing risk to children (including unborn children) and clients during the wait time. There may be further opportunity to systematically provide information on the effects of AOD on unborn children to those on the waitlist via referrers and to consider whether there is a way to provide this information to all PPS clients (whether pregnant or not) without compromising the PPS approach of focusing on what is important to the client in the context of managing more immediate risk.

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Domain 3. Client and whānau health, safety and wellbeing File review and interview findings indicate that AOD-related harm reduces for PPS clients. Clients frequently attribute their ongoing abstinence or reduction of AOD use (and related harms) to the support received from PPS. Outcomes data on the impact of AOD use on parenting generated via the V-ADOM were not consistent with file and interview data for baseline ie, V-ADOM results show that for more than 80% of clients, AOD use did not interfere with parenting, while interview and file data suggests that parenting was significantly negatively impacted for many clients. Reasons for this disparity require further exploration. Clients demonstrate increased awareness that violence is unacceptable and increased awareness of the negative impacts of violence on their lives and the lives of their children. Many PPS clients develop their understanding of what constitutes safety in relationships and are able to apply this. These findings align with the findings in Domain 1 relating to reduced exposure of children to AOD and violence. Additionally, there is indication from file review and interviews that clients strengthen their support networks. Files show that clients access supports and services and clients describe accessing support and services, and knowing how to get help if they need it. For clients who are Māori, this includes developing cultural links, exploring cultural identity and spirituality, strengthening whānau relationships and accessing cultural support. Other outcomes Findings highlight the focus given to developing PPS clients’ confidence, self-efficacy, empowerment, self-determination and self-responsibility. These contribute to the achievement of all outcomes discussed above and set clients up to maintain their gains once discharged from PPS. Accordingly, there is evidence that clients improve their ability to look after themselves and their children and handle life’s ongoing challenges in a healthier way. In particular, several clients talked about their experience of setting and achieving goals and how valuable this has been for them in giving them agency in their lives.

Conclusion Overall, the PPS model is effective in achieving intended outcomes, especially in reducing exposure of children to AOD and violence, and the service and the approach is highly valued by clients. Mindful of the data collection and other methodological limitations outlined above, it is not possible to solely attribute the achievement of these outcomes directly to PPS intervention, it is, however, notable that many of these outcomes occur subsequent to engagement with PPS and that clients frequently make this attribution. Feedback confirms that PPS provides a highly professional, structured and non-judgmental service to clients, while maintaining an unwavering focus on the safety and wellbeing of children within the context of their family and whānau. Comments from clients and whānau members interviewed for this evaluation universally confirmed this.

In terms of learning from this evaluation it is suggested that PPS continues to maintain the current high quality service delivery model and explores enhancements as follows:

Consider reviewing practices for providing information on the effects of AOD use in pregnancy so that all PPS clients and those on the PPS waitlist who are pregnant have the benefit of this information.

Investigate the issues with the V-ADOM highlighted in this report to better understand its application and utility with this client group/service model.

Undertake work to strengthen the Pre-treatment and MDT Review forms for the purposes of measuring outcomes in future, or identify other tools better suited to the task.

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Caspi A. Renate M. Houts RM. Belsky DW. Harrington H. Hogan S. Ramrakha S. Poulton R. & Moffitt T. 2016. Childhood forecasting of a small segment of the population with large economic burden. Nature Human Behaviour Vol 1. Article number: 0005

Galea S. & Websdell P. 2011. The Visual ADOM: Looking good. Drug & Alcohol Review, Vol. 30, Suppl. 1, pp.35.

Heckman J. The Case for Investing in Disadvantaged Children. www.heckmanequation.org. Retrieved February 2015.

Ministry of Health. 2015. Supporting parents healthy children. Wellington: Ministry of Health.

Ministry of Social Development. 2012. The White Paper for Vulnerable Children. Vol I. Wellington: New Zealand Government.

Ministry of Social Development. 2012. The White Paper for Vulnerable Children. Vol II. Wellington: New Zealand Government.

Parsonage P. 2015. Waitemata DHB CADS Pregnancy and Parenting Service: Process evaluation. Wellington: Health Promotion Agency.

Poole N. 2000. Evaluation report of the Sheway Project for high-risk pregnant and parenting women. Vancouver: British Columbia Centre of Excellence for Women’s Health.

Poulton R. The nature of our nurture genes x environment = human behaviour. BPAC 2008 Vol 16: 4-5.

Pulford J. Deering D. Robinson G. Wheeler A. Adamson S. Frampton C. Dunbar L. & Paton-Simpson G. 2010. Development of a routine outcome monitoring instrument for use with clients in the New Zealand alcohol and other drug treatment sector: the Alcohol and Drug Outcome Measure (ADOM). New Zealand Journal of Psychology Vol 39(1): 35-45.

Waitemata DHB. 2016. CADS PPS Model of Care. Auckland: Waitemata DHB.

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Appendix 1. Waitlist Management

2.1 Waitlist Management10

All referrals are reviewed at the PPS weekly MDT review meeting. They are discussed by the team and their acuity rated from 0 to 5 is given with 1 being the lowest rating. This rating is based on assessment of the clients: • Current substance use • Current mental health issues • Housing situation • Presence or level of current family/whanau violence • Pregnancy • Children in their care • Presence of other services and level • Presence of other supports and level • Children in care or previously removed • Under 20 years of age Each of the above is given a 0.5 rating and the final acuity is rounded up or down depending on clinical judgement. Other factors considered at referral and when the waitlist is reviewed include (though are not limited to): • Antenatal care • Intravenous use • Number of children • Inconsistent information • If unborn is to be taken into care at birth • Window of opportunity • More than 3 months on the waitlist • Whether clients partner is referred to the service Sometimes a high level of acuity can be mitigated by a single protective factor. Decisions are based on clinical judgement informed by the above factors and team agreement. Referrers are contacted, informed that their client is on the waitlist and of recommendations generated at the MDT. Referrers are asked to inform PPS if the client’s situation changes as this may increase or decrease the level of acuity. Clients are allocated as soon as a place becomes available. New staff building caseloads will have a range of acuity levels allocated. The waitlist is reviewed by the Clinical Team Leader and the Clinical Nurse Specialist. The acuity is either increased, reduced or remains the same. The process is as follows: • Acuity 4 and 5 reviewed monthly • Acuity 3 and 2 reviewed bi -monthly • Acuity 0 and 1 reviewed quarterly Follow up occurs if indicated.

10

Waitemata DHB PPS Model of Care, 2016 p.8