A mixed-method evaluation of a statewide transitional housing program for young adults with mental health disorders

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Linette Bailey
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LCSW John Holland, PhD, LCSW State of Connecticut Department of Mental

1 A mixed-method evaluation of a statewide transitional housing program for young adults with mental health disorders Jennifer Abbatemarco, LCSW John Holland, PhD, LCSW State of Connecticut Department of Mental Health & Addiction Services Young Adult Services 3/6/2018 Young Adult Services

2 Background Young adult services (YAS): o Intensive Mental Health Treatment o Comprehensive Community Supports o Trauma-Informed o Recovery - Oriented

3 Who we serve o DMHAS serves approximately 16,000 young adult age clients each year o About 1,500 of these clients are served in Young Adult Services (YAS) o 100 are living in YAS transition programs

4 Who we serve year olds who have: o Multiple hospitalizations prior to age 18 o Complex, developmental trauma o An average of 7-10 out of home placements before age 16 o Significant attachment disorders which make treatment engagement very difficult o May have co-morbid substance abuse issues o Have not had the opportunity to learn any of the necessary life skills or emotion regulation skills to cope with daily challenges o Lack of educational/vocational experiences o Have not had the opportunity to experience and transition through the typical developmental tasks of young adulthood

5 Consensus on Core Values of YAS To provide services that are: o Developmentally appropriate o Offer a broad array of clinical and community living opportunities o Trauma-informed and trauma-sensitive o Easily accessible To provide intensive treatment that: o Is offered both in a clinic setting and in the community o Utilizes assertive outreach to engage clients and provide hands-on support and skill training in vivo o Emphasizes recovery values of growth, empowerment and community integration

6 Services o o o o o YAS includes 18 community based programs throughout Connecticut as well as other levels of support including specialized residential settings and an inpatient unit. Clinical services include: Trauma-informed, recovery-oriented therapeutic interventions Case management Psychopharmacological interventions Community participation and integration services include: Occupational therapy Educational/v0cational services and supports Money management training and financial services Housing opportunities Positive peer activities (recreational) The goal is to help vulnerable youth make the transition to adulthood by emphasizing management of mental health recovery and completion of typical developmental tasks. Emphasis is on building skills for community living.

7 YAS transition programs o 14 supervised community-based living programs statewide with hours/day of on-site staff support (approximately 100 beds) o Allow young people extra time and resources to learn and develop the skills they need to live independently in the community o Provide intensive wrap around support (i.e. life skills, vocational and educational opportunities, case management, etc.) o Provide opportunities for positive ( pro-social ) activities o Provide a safe and nurturing environment to promote recovery from mental health and substance use o Are in high demand, limited in availability

8 YAS transition programs Program highlights include: o Targeted length of stay = 18 months o Trauma informed approaches using the Attachment, Regulation, and Competency Model (ARC) o Intensive on-site support around life skills development, vocational/employment needs, and mental health and substance abuse recovery o Discharge occurs when clients have achieved maximum gains, leveled off, or are no longer participating in the program o Successful outcome = discharge to lower level of care

9 YAS transition programs Life skills programming includes: 1. Money Management 2. Food Management 3. Personal Appearance & Hygiene 4. Home Management 5. Housing 6. Transportation 7. Emergency & Safety Skills 8. Health & Wellness 9. Knowledge of Community Resources 10. Pregnancy Prevention

10 Data informed decision making o Are considered key components to ensure best practices and to more efficiently and effectively manage these resources (Douglas, et al. 2010) o Research supports the systematic review of cases at regularly defined intervals to determine whether services should remain the same, change or end (Jackson, et al. 2015) o Most gains in treatment are made early on and level off or plateau over time. (Jackson, et al. 2015)

11 Research question: What are the discharge outcomes of the YAS Transition Programs?

12 Methods o Sample Includes 122 consecutive admissions to YAS Transition Programs between 3/1/2012 and 12/11/2017 o Only included Transition Programs with 24-hour staff support o Initial data collection began on 10/13/2016 o Measures were taken every quarter until discharge o A sub-sample of 31 consecutive discharges is also included in the sample. The discharges occurred between 11/01/2016 and 11/16/2018

13 Descriptive statistics Name Mean SD Age Admission All D/C Cohort Number Percent Gender (Admission) Male Female Gender (Discharge) Male Female

14 Descriptive statistics Name Mean SD Length of Stay (Discharge) Age (Discharge) Number Percent Special Funding (Admission) Yes No Special Funding (Discharge) Yes No

15 Risk admission & discharge x 2 (3) =8.675, P =.034 Risk ED Admission ED Admission D/C No Risk Low Moderate Severe 0 No Risk Low Moderate Severe

Risk admission & discharge Risk - Arrest Admission Arrest D/C 90 90 80 80 70 70 60 60

16 Risk admission & discharge Risk - Arrest Admission Arrest D/C No Risk Low Moderate Severe 0 No Risk Low Moderate Severe

Risk admission & discharge Aggression Admission Aggression Risk Discharge 90 90 80 80 70 70

17 Risk admission & discharge Aggression Admission Aggression Risk Discharge No Risk Low Moderate Severe 0 No Risk Low Moderate Severe

18 Risk admission & discharge x 2 (3) =8.857, P =.012 SIB Admission SIB Risk Discharge No Risk Low Moderate Severe 0 No Risk Low Moderate Severe

19 Risk admission & discharge Drugs Admission Risk Drugs No Risk Low Moderate Severe 0 No Risk Low Moderate Severe

20 Risk admission & discharge Suicide Admission Suicide Risk No Risk Low Moderate Severe 0 No Risk Low Moderate Severe

Risk admission & aischarge Admission PSB PSB Risk 100 100 90 90 80 80 70 70 60 60 50

21 Risk admission & aischarge Admission PSB PSB Risk No Risk Low Moderate Severe 0 No Risk Low Moderate Severe

22 Risk admission & discharge Other Risk Admission Risk - Other No Risk Low Moderate Severe 0 No Risk Low Moderate Severe

23 Change in "No Risk" Pre/Post Other PSB Suicide Drugs SIB Post Pre Aggression Arrest ED

24 List scores admission & discharge Mean SD List Admission List Discharge Mean Difference + 3 Paired Sample T-Test: t (23) = , p=.068 Not statistically significant but oh so close

25 82% discharged successfully! Discharge Reason Lower LOC - Succesful D/C Moved Other/Unknown Declines Svs Higher LOC No discharges due to incarceration or hospitalization

26 90% discharged to independent housing in the community LOC at Discharge Own Apartment Specialized Other/Unknown

27 Results o No Risk increased between admission and discharge except with Drug Use = No Risk Decreased o These changes in risk designation, when all variables are included, were statistically significant in the cases of ED admissions and self-injurious behavior o Severe Risk increased between admission and discharge in drug use and risk of arrest o Very high rates of successful discharge to community housing

28 Qualitative evaluation Method: o Semi structured interview format o 6 former transitional program young adults participated in the interviews o Recorded and transcribed by two researchers o Independent open coding using primarily descriptive codes o Iterative second coding both researchers together

29 Categories Life skills Development of Home Management Aptitude and Learning Organizational Skills before I got in transition I wasn t able to, you know, I wasn t prepared, I was more dirty, you know, hygiene stuff but then living in transition how it helped me is that staff live right there, right near me. They could easily come up or I could easily go downstairs to them and ask for help. And they were more than happy to help me.

30 Categories Staff support Staff Availability, Attunement & Mentorship I remember one time I heard news about my dad. He was having a really bad time with his health. I was balling my eyes out so I went to the staff at like 11 o clock at night and they talked to me. We went for a ride, out somewhere just to go talk and have someone to talk to. It made me feel much better.

31 Categories Independence Work, School, Decision-making, Living Apart from Parents The only thing was that I didn t feel like I was ready to go out in the community. I m very hesitant about a lot of things. So, I m going to say that what I did learn (at the program) was how to push myself out of my comfort zone.

32 Categories Recovery Learning to Live with Mental Health Problems, Moving Past the Illness Identity, Participating in a Recovery Community because I was away from my parents and there were people around me that knew about mental health and they could answer questions I had. My dad and stepmom didn t know a lot about my mental illness, so they really couldn t give a lot of answers. But here usually people are like Oh I know about that. I ll tell you about this. And it was really comforting.

33 Categories Having a voice Assertiveness, Engaging in Self-Advocacy I just needed to be heard. And you know sometimes staff isn t enough so higher up like Victor (senior Leadership). You don t have to ask for help when things get too bad. You can ask for help before it gets to a point where it s a crisis.

34 Themes 1. Young adults found the transitional apartment program met their needs at that time, as a bridge between family home/ institutional settings and complete autonomy. The program is developmentally informed, with just the right amount of support and structure, to begin the process of laying down a foundation for adulthood. 2. Connection to staff and peers, connection to the community through school and work, was facilitated by the transitional apartment program.

35 Next steps for program evaluation (quantitative) oimprove data collection targeting changes in life skills (validity & reliability) omeasure 3 mos, 6 mos, 12 mos post-discharge to determine stability of gains

36 Next steps for program evaluation (qualitative) o Explore concerns about staff communication oimprove overlap of clinical services and transitional apartment programming

37 We d love to hear from you! Jennifer.Abbatemarco@ct.gov John.Holland@CT.Gov

38 References Douglas, S., Button, S., & Casey, S. E. (2016). Implementing for sustainability: Promoting use of a measurement feedback system for innovation and quality improvement. Administration and Policy in Mental Health and Mental Health Services Research, 43(3), /s Jackson, D., Keir, S., Sender, M., & Mueller, C. (2015). Reliable change and outcome trajectories across levels of care in a mental health system for youth. Administration and Policy in Mental Health and Mental Health Services Research, 42, doi: /s

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Covered Service Codes and Definitions [01] Assessment Assessment services include the systematic collection and integrated review of individualspecific data, such as examinations and evaluations. This