HomeMy WebLinkAboutMINUTES - 07271993 - 1.45 1 . 45
TO: BOARD OF SUPERVISORS �
FROM- Mark Finucane, Health Services Director / Contra
By: Elizabeth A. Spooner, Contracts AdministratCosta
DATE: July 15, 1993 io County
SUBJECT: Approve submission of Funding Application #29-481 to the U.S.
Department of Health and Human Services (Office of Substance
Abuse) for the "Women's Continuum of Care" Project
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION:
Approve submission of Funding Application #29-481 to the U.S. Depart-
ment of Health and Human Services, in the amount of $500, 000 per year,
for the period from September 30, 1993 through September 29, 1996, for
the "Women's Continuum of Care" Project.
II. FINANCIAL IMPACT:
Approval of this application by the U.S. Department of Health and
Human Services will result in $500, 000 for each year of a three year
"Women's Continuum of Care" Project. No County funds are required.
III. REASONS FOR RECOMMENDATIONSIBACKGROUND:
The Center for Substance Abuse Treatment (CSAT) has announced a
continuation of its Critical Populations Demonstration Grant Program
to expand the availability of high quality treatment services for
individuals who suffer from alcohol and drug problems.
The "Women's Continuum of Care" Project is an effort to expand the
delivery of innovative services to female residents of the County who
have an identified substance abuse problem and are currently seeking
substance abuse treatment, and their children.
In order to meet the deadline for submission, the application has been
forwarded to the U.S. Department of Health and Human Services, but
subject to Board approval. Three certified copies of the Board Order
authorizing submission of the application should be returned to the
Contracts and Grants Unit for submission to the U.S. Department of
Health and Human Services.
�-
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMME ATIO OF BOARD CO MITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER
VOTE OF SUPERVISORS
UNANIMOUS (ABSENT-� ) I HEREBY CERTIFY THAT THIS IS A TRUE
AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN
ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD
OF SUPERVISORS ON THE DATE SHOWN.
Contact: Chuck Deutschman (313-6350)
cc* Health Services (Contracts) ATTESTED o`
Auditor-Controller (Claims) P 1 Batchelor, Clerk of the Board of
U.S. Department of Health and $ 8ryMF3pdGWtyAdWnL*atV
Human Services
M382/7-e8 BY DEPUTY
Mary Foran, Californias o (�
Chuck Deutschman, California 11
WOMEN'S CONTINUUM OF CARE PROJECT NARRATIVE
A. BACKGROUND AND SIGNIFICANCE
Overview and History. Traditionally, services for substance abusers have addressed the male as the
typical client. Although modified in recent years with the advent of ancillary services for families, the
basic model remains one of taking the client "out" of his everyday life in order to provide treatment.
With women substance abusers, this approach has often proven impractical as well as ineffective. Recent
literature and new program models (see below) take a more "holistic" view of women substance abusers,
and include attention to roles many women play as mothers, and often as heads of households. The need
for treatment and recovery programs to address the reality and context of women's lives has led to an
inclusion of related services, e.g., health care, childcare, parenting education, housing, transportation,
and job and life skills into thetreatment approach.
The Contra Costa Health Services Department has responsibility for all major health-related functions
within the County. Major administrative Divisions within the Department are Public Health; Mental
Health; Substance Abuse Services; Merrithew Memorial Hospital and Clinics, a staff-model family
practice-based system of ambulatory care health centers with a 189-bed hospital; Contra Costa Health
Plan, a publicly-sponsored, federally-qualified health maintenance organization which serves a mix of
Medicaid, Medicare and commercial enrollees; and Environmental Health. All Divisions report to the
Health Services Director who 18 months ago established the Office for Service Integration with
responsibility for integrating programs across the Divisions of the Department so that clients are served
more efficiently and effectively.
Integration of services for pregnant and parenting women and their families has been and continues to
be one of the Department's highest priorities. The emphasis on services for substance abusing women
began in 1986 with the funding of Tri-County's Women's Recovery Services to open the first facility in
the county for women and their children. Since that time, the Department, in collaboration with
community agencies, has developed a number of programs to address the needs of substance abusing
women. In 1987, the Department formed the Alcohol, Drug Abuse, and Perinatal Task Force(ADAPT),
bringing together service providers from throughout the county to develop policies and programs to
address the newly recognized problem of perinatal substance abuse. ADAPT continues to meet monthly
to share information, identify priorities, and develop programs to respond to new needs as they are
identified.
As a result of the collaboration fostered by ADAPT and other task forces, the County has received a
number of grants for women's services. The Born Free Project, funded in 1989, by the Center for
Substance Abuse Prevention(CSAP, formerly OSAP), is currently in its fourth year of providing services
at three sites in the County. Born Free has created a model of intervention and outpatient treatment
services with pregnant and postpartum women which is fully integrated into the prenatal care and labor
and delivery services of the Department. (Between 70 and 80% of the low income women in Contra
Costa County enroll in the County's perinatal services.) In 1990, CSAP funded the Social Service
Department's Living Free Project to serve women and their drug-exposed infants at risk of out-of-home
placement in the western region of the County. In 1991, the non-profit Early Childhood Mental Health
Program's Infant Bond Project was funded by the State of California Office of Child Abuse Prevention,
United Way and private funding to provide home-based substance abuse counseling and support services
to substance abusing women with newborns, also in the western end of the County. Begun in 1987, the
Pittsburg Pre-School Coordinating Council provides therapeutic infant and toddler care to 15 children
from drug- and alcohol-involved families.
With the addition of funding from the State of California in 1991, the network of treatment services for
substance abusing pregnant and parenting women and their children was expanded further. The Options
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for Recovery (OFR) and Perinatal Treatment Expansion Project (PTEP) combined to fund 45 additional
residential recovery beds for women and their children in all three regions of the county, and two
intensive outpatient day treatment programs. In addition, OFR supports intensive case management
services and a special foster parent recruitment, training, and respite care project. Additional PTEP funds
support group counseling services for women in the County jail by Born Free, as well as expanded
capacity in the Born Free outpatient treatment services. See Map A in Appendix IV for graphic display
of existing services for women. The Women's Continuum of Care Project (WCC) proposed for
funding will add essential services to the existing network of outpatient programs for women.
The Contra Costa County Health Services Department's programs for substance abusing women have
remained on the cutting edge of substance abuse treatment knowledge. Service providers have kept
abreast of the latest research and findings in the field, and have contributed to developing new knowledge
as evidenced by requests from other providers throughout the nation for information about their
innovative programs. Most recently, in January, 1993, the County Health Services Department received
the Exemplary Services Award from the California Department of Alcohol and Drug Programs for its
perinatal substance abuse services. On Mother's Day of this year, Dr. Andrew Mecca, Director of the
State Alcohol and Drug Program visited Contra Costa County's Born Free Project and participated in a
celebration to honor recovering women from all of Contra Costa's programs. In addition, the Born Free
Project received the 1990 Top Honors Award f'or Innovative Programs from the California Public
Hospital Institute and in 1993, won the Community Achievement Award from the Alameda/Contra Costa
Perinatal Network.
Key Issues for Treatment and Recovery for Substance Abusing Women and their Children. A
review of the literature confirms the experience of service providers in identifying the key issues to
consider when designing effective services for substance abusing women and their children.
Treatment: In a review of treatment programs and research concerning women's needs to achieve
successful drug treatment, Brown (1992) finds that treatment programs must be designed to account
women's psychological makeup; particular life stresses, including the need to care for their children;
sexual and physical abuse; and overall medical, economic and social needs. The issue of physical and
sexual violence in substance abusing women's lives must be addressed during treatment; clinicians and
researchers are reporting increasingly high rates of addiction to alcohol and other drugs among women
who have childhood histories of physical and sexual abuse (McKinney, 1993).
Recovery/Continuing Care: In a review of the literature on indicators of recovery outcomes, Mumme
(1991)found no formal research studies focusing on women. Although studies may have included "some
women," outcomes were not analyzed using gender as a variable. Studies of the male population did
reveal a"significant correlation between aftercare and a greatly increased prognosis of treatment success."
The literature identified successful recovery as linked to "continuing care" from residential facilities
where treatment was received; ongoing counseling and group work increasingly oriented toward
community integration;participation in A.A. and/or N.A. or similar self-help groups;treatment of relapse
as part of recovery rather than as failure; and family therapy. (ibid.)
Prenatal Alcohol and Drug Use Health Impacts on Children: Research has shown that cocaine use
throughout pregnancy can be associated with systemic growth retardation in offspring, resulting in
reductions in both birthweight and head circumference (Finnegan and Kandall, 1992). Additionally,
Chasnoff (1985) reported an increase in degree of irritability and tremulousness, in cocaine-exposed
infants. In 1992, Chasnoff published a two-year follow-up study of infants with cocaine and poly-drug
exposure. Although he reported some developmental delays still in evidence, Chasnoff concluded that
maternal motivation and participation in nutrition, drug treatment, and pediatric follow-up helped to
ameliorate effects of prenatal exposure.
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The effects of maternal use of alcohol, heroin, tobacco, and amphetamines during pregnancy are better
documented. Finnegan and Kandall (1992) report that heroin and methadone withdrawal in the newborn,
"neonatal abstinence syndrome," is characterized by neurobehavioral symptoms including central nervous
system hyperirritability,gastrointestinal dysfunction,respiratory distress,tremors, and sleep disturbances.
They also write that Fetal Alcohol Syndrome (FAS) is now believed to be the leading cause of mental
retardation in the United States. Approximately 2.6 million infants a year in the United States are born
with FAS.
Services for Drug and Alcohol-Exposed Children: From a child development perspective, Rinket(1992)
argues for a combination of early intervention and an individualized approach to assessment and
evaluation which looks at environmental variables such as stability and structure in children's lives along
with amount and type of in utero exposure. Children with prenatal exposure to drugs and alcohol require
a range of health care and developmental services. Service requirements vary with the degree of prenatal
exposure and the ability of the mother to provide effective parenting. According to the California Policy
Seminar of the University of California (1992), children with prenatal exposure to alcohol and/or drugs
require ongoing well-child health care services, preferably by providers who have consistent relationships
with them. For newborns who exhibit withdrawal symptoms, more active intervention and home visits
by public health nurses, as well as on-going support and parent education about children's health and
behavior issues, are also necessary.
Services for "Dual-Diagnosis" Women: The term "dual diagnosis" refers to the coexistence of substance
abuse and mental illness. Zweben (1992) describes how the historical separation of the mental health and
substance abuse treatment systems has led practitioners from both systems to provide inadequate services
to substance abusers with psychological disorders. Research suggests over 70% of hospitalized alcoholics
have experienced one or more episodes of psychiatric disorders in their lifetimes. High rates of
psychiatric disorders are also reported for drug addicts as well. (Hesselbrock, Meyer and Keener, 1985)
(Carroll and Sobel, 1986) Although the literature documents the prevalence of substance abuse among
the psychiatric population, there is a lack of proper screening for substance abuse in such facilities;
patients may be excluded from admission when substance abuse is identified. Similarly, in the addiction
treatment system, programs which rely heavily on recovering staff members who have had little or no
training in treating mental illness may fail to recognize psychopathology (Beeder and Millman, 1992).
Zweben advocates a recovery-oriented therapy model which integrates elements of the recovery model
such as abstinence commitment, education, breaking the addiction cycle, creating new life styles, and
renegotiating relationships, while simultaneously exploring long-term psychological issues. Zweben
recommends that the disjunction between the mental health and substance abuse systems be addressed by
"cross-training,"familiarizing practitioners within both mental health and addiction treatment systems with
the assumptions and terminology of their counterparts. Daley, Moss, et al (1987) indicate that teamwork
and close collaboration between substance abuse and mental health professionals particularly in the areas
of assessment and follow-up treatment is essential.
Model Programs for Substance Abusing Women and Their Children. The literature sources on
substance abuse treatment and recovery, effects of perinatal substance exposure, and related health
problems all point to the need for a comprehensive continuum of services. In developing services to
substance abusing women, the Contra Costa County Health Services Department has drawn from a
number of models of comprehensive service provision.
National Model: The CSAT Treatment Improvement Protocol (April 18, 1993) for Pregnant Substance
Abusing Women provides direction to health care providers concerning the scope of care required for
successful obstetrical and follow-up care. The key notion expressed in the protocol is that of
"comprehensive" care (see also, CSAT Comprehensive Care Continuum). The pregnant, substance
abusing woman experiences an array of life circumstances: social, medical, and economic, as well as
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substance abuse. The model tailors the treatment to address women's needs. For example, in order for
a woman to benefit from substance abuse treatment, she might need reliable childcare, transportation, a
sober living environment, health education, and/or mental health services. The model also incorporates
case management as an integral part of treatment and identifies the importance of providing continuing-
care.
California Model: In 1989, California Department of Drug and Alcohol Programs initiated and
developed with the California Department of Health Services, Maternal and Child Health Branch, and
Department of Social Services, a "Select Committee" of experts on substance use during pregnancy.
Among other initiatives, the result was the Options for Recovery Model (OFR). The OFR collaborative
model of case management, drug and alcohol treatment, and specialized social service has been
implemented in ten counties including Contra Costa County.
Local Model: Contra Costa County's model of services for substance abusing women emphasizes three
key approaches. First, Contra Costa's services are firmly rooted in the national and State models of
comprehensive services to support women's recovery, with emphasis on being family-centered and
attentive to the needs of children.
Second, the experiences of implementing the comprehensive approach has lead to the articulation of a
"Family Recovery Model" which blends elements of the medical and social models — eg., highly trained
professional staff work side by side with recovery staff, both group process work and individual and
family therapy sessions are required of participants; maternal and child health-oriented case managers
work conjointly with treatment and recovery staff.. The Family Recovery Model also emphasizes the
necessity of interweaving cultural traditions from all the participants represented in the treatment
population into the treatment/recovery activities. Consistent with the emphasis on cultural inclusiveness
and celebration of diverse traditions of resiliency, strength and hope is the goal of rebuilding
communities.
Third, Contra Costa County has taken a broad systems, and at the same time, an incremental approach
to building a network of services for women. Collaborative planning among county government and
community agencies, and across the professional disciplines of substance abuse treatment, social model
recovery, health care, child development, child protection, law enforcement and education has been
consistent and essential to success. From beginning with the first Tri-County Women's Recovery
Services recovery home in 1986, to initiating Born Free on a pilot basis in 1988, to adding a significant
number of recovery beds and outpatient services for women and children in 1991 and 1992, the County
has been guided by a philosophy which says recovery for pregnant and parenting women is possible;
publicly funded comprehensive services are essential to supporting recovery; and services which are
geographically dispersed and culturally competent are necessary to provide access to all those seeking
help.
The Women's Continuum of Care Project is the next step in the development of the network of services
for women. By filling in crucial gaps in the current system of services, it will increase the possibility
of successful recovery for Contra Costa women and their children.
B. TARGET POPULATION AND NEEDS ASSESSMENT
Description of the Area. Contra Costa County is a geographically and demographically diverse county.
The County covers 732 square miles which are divided into three distinct areas separated by hills: West
County, Central County, and East County. West County and a portion.of East County are densely
populated areas with disproportionate African American, Latino, and Asian populations, and a
correspondingly disproportionate number of individuals living in poverty. Central County is comprised
primarily of bedroom communities with higher incomes and educational levels. East County, a once
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thriving agricultural/industrial area, is rapidly converting to a residential tax base. (See Map B in
Appendix IV for identification of key cities in each area.)
Contra Costa County is characterized by striking polarization. Despite a median household income of
$45,087 (1990 Census), the County also contains some of the poorest census tracts in the State. 138,234
individuals (17% of the County's population) have incomes below 200% of the Federal poverty line.
Fourteen percent of West and East County residents receive public assistance, compared to only four
percent of residents in the central part of the County.
Because of the size of the County, the geographic barriers, and the distribution of poor communities
across the County, services must be organized regionally. As a result the Health Services Department
maintains a network of geographically dispersed primary care health centers, mental health centers, public
health services and substance abuse programs. In addition,these services, especially substance abuse and
mental health services, are often provided in collaboration with community-based organizations which
reflect the particular characteristics of the various service populations.
The Target Population. Services proposed under this application will be for women ages 12 to 44 and
their children (to age 10). In Contra Costa County, there are 202,500 women in this childbearing age
group, of whom 15% are aged 12 to 17, 17% are aged 18 to 24, 32% are aged 25 to 34, and 36% are
aged 35-44.
According to the 1990 Census, the County population was 803,732, with 601,644 adults and 202,088
individuals under age 18. The racial/ethnic breakdown of County residents is 70% White, 11% Latino,
9% African American, 9% Asian/Pacific Islander, 1% Native American, and less than 1% "other".
However, the overall population statistics do not reflect the fact that the County's African American,
Latino,.Asian, and Native American populations live in concentrated geographic areas. For example,
in East County, the city of Pittsburg's 47,564 residents are 23% Latino, 17% African American, 11%
Asian, 1% Native American, and 47% White. In West County, the city of Richmond has a population
of 87,425, with 43% African American, 15% Latino, 1% Native American, and 31% White.
The chart below shows the female population of Contra Costa County by age and racial/ethnic group.
Each year approximately 13,000.Contra Costa women have new babies, including an estimated 375 young
women under the age of 18.
AGE TOTAL
12-17 18-24 25-34 35-44 # %
African American 3596 4295 1069 6460 15420 7.6
Hispanic 1693 2341 3654 2353 10041 5.0
White 20454 24808 52844 55006 53112 75.6
Asian/Pacific Is. 3506 3499 7327 8051 22383 11.0
Native American 222 278 553 491 1544 0.8
TOTALS 29471 35221 65447 72361 202,500 100.0
Source:1990 Census, compiled by Association of Bay Area Governments, Regional Data Center
i
Indicators of Need for the Target Population
Prevalence and Type of Substance Abuse: Substance abuse by women is a problem in each geographic
and demographic group in Contra Costa County. Data collected through the State of California's
Alcohol and Drug Data System (CADDS) shows that during the period of January through December
1992, a total 2450 women received services from County providers. 58% of the women received
detoxification services either residential (38%)or outpatient(20%). Thirty-one percent received treatment
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services, of which 6.6% were in day treatment programs and 11 % were in residential recovery services.
Of these, 41.7% were reported to have either completed treatment or left the program with a satisfactory
status. The race/ethnicity of clients served were: 48% White; 44% African American; 6% Hispanic;
and 2% Other (Native American and Asian/Pacific: Islander).
Data was collected on the primary substance of use. For the entire female population served, 42%
identified alcohol as the primary substance; 25% for heroin; 20% for crack/cocaine; and 9%
methamphetamine/amphetamine. Almost 34% report having used needles in the past year in conjunction
with substance use. Seven percent of the women were pregnant at the time of admission to programs.
Type of substance used varied by race/ethnicity and age. Heroin users were primarily White; 74%, while
18% were African American and 6% Hispanic. In contrast, 79% of the crack/cocaine users were African
American, 16% were White and 3.5% Hispanic. Methamphetamine/amphetamine users were primarily
White (80%) and Hispanic (11%), with 4.6% African American.
In early 1993, Options for Recovery conducted a limited chart review that revealed 58% of the women
in treatment were crack users and 81% also used alcohol. Forty-two percent of the women had never tried
treatment before being in OFR. There was tobacco use by 42% of the women.
HIV/AIDS Infection: By December 31, 1992, Contra Costa County had reported 895 AIDS cases, using
the 1987 AIDS definition (Contra Costa County Communicable Disease Quarterly Report, 1993). Of
these, 15% were heterosexual injection drug users, more than double the California statewide figure of
7% (ibid). Using the 1993 expanded AIDS surveillance case definition, the percentage of diagnosed
AIDS cases among females has almost doubled — from 9.6% under the earlier definition, to 18.1% under
the 1993 definition. (ibid.)
Additionally,while Contra Costa County has approximately 2.7%0 of California's population, it has 4.4%
of the reported cases of AIDS in injection drug users (ibid). Blind seroprevalence surveys of methadone
treatment clients conducted from 1989 through 1992 show the seroprevalence levels for injection drug
users entering methadone detoxification programs at 9.3% for all clients (ibid). Street surveys of current
out-of-treatment injection drug users, conducted in 1.991 and 1992 in the city of Richmond by the Institute
for Health Policy Studies (University of California San Francisco), show an HIV seroprevalence of
22.9%. These figures.were double the rates of the other sites in this study which included drug impacted
areas in Oakland and San Francisco (CCC Communicable Disease Quarterly Report 1993).
According to the fourth annual HIV seroprevalence survey of childbearing women in California compiled
by the California State Office of AIDS, the rate of HIV infection in California was one in 1,249 women
(.08%) and in Contra Costa County one in 852 women (.117%) (Contra Costa County Quarterly Report
of HIV/AIDS Statistics, July-September 1992). Approximately 16 children a year are born to infected
mothers in Contra Costa County and five are likely to be infected with HIV (ibid). As of June 1992, 32
infants and children from Contra Costa County were being treated at Children's Hospital in Oakland, a
regional center, for HIV disease.
Tuberculosis(TB): Contra Costa County's Communicable Disease Program, has been in the forefront
of documenting the link between the AIDS epidemic, drug use, and the resurgence of TB, including
providing evidence to the Centers for Disease Control to establish the link between AIDS and TB.
According to the Contra CostA County Quarterly Communicable Disease Report, 1993, since 1985, there
has been a 71% increase in the rate of TB in Contra Costa County. In 1992, there were 117 cases
reported. Six patients are currently being treated for multiple drug resistant TB.
Syphilis: Rates of syphilis infection, often associated with the use of crack, increased from 55 cases per
year in 1986 in Contra Costa County to over 300 in 1988. In 1989, 320 cases were reported and in
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1990, 337. The number of cases reported in 1991 decreased to 250, attributable to aggressive STD
investigative and follow-up treatment services (Contra Costa County Health Services Department).
Resources to Combat STD's.TB, HIV/AIDS. Contra Costa County Health Services Department places
a high priority on outreach, education,screening and intervention services for STD's, TB and HIV/AIDS.
As of April 30, 1993, the County began utilizing a mobile clinic to test for and treat TB, HIV, and
STD's. The target population is women who are prostitutes, or who exchange sex for drugs, and their
partners. The clinic now operates each Friday in selected areas in East and West County, chosen based
on incidence data for communicable disease.
The HIV/AIDS Office Program operates a nationally recognized active street outreach program to provide
education and testing to high risk groups such as intravenous drug users, homeless people and others on
the street. It is the policy in the County prenatal care clinics to encourage every pregnant woman to be
tested for HIV and all women receive extensive risk reduction education. The prenatal Social Workers
act as Case Managers for any woman identified as positive through screening in prenatal care. Finally,
Options for Recovery and the HIV/AIDS Office Program developed and presented a "HIV/AIDS,
Pregnancy, and Substance Abuse Training Series" for treatment, social service, and health care providers.
The training series wi11 be offered on a regular basis.
The TB and STD outbreaks in Contra Costa County are under constant scrutiny. However, continuing
budget cuts mean that resources are sometimes shifted to handle outbreaks and ongoing maintenance of
community education and prevention can be compromised. In addition, Public Health STD clinics, HIV
Anonymous Test Sites and TB screening functions rely on people at risk coming to them. For a high risk
population such as substance abusing women, a much more reliable approach is to bring the services to
them.
Perinatal Care: The infant mortality for County residents has decreased-from 10.3 deaths per 1,000 live
births in 1981 to 6.4 deaths in 1990, representing a decrease of 37.9%. Although there was a striking
44.7% decline in African American infant mortality from 1981 to 1990, in 1990, African American
infants remain 1 1/2 times more likely to die than White infants in their first year of life. Over the past
decade, the percentages of low birthweight births for the County fluctuated very little, remaining close
to 6.0%. While the low birthweight percentages for Whites decreased slightly from 4.9% in 1981-1985
to 4.8% in 1986-1990, during the same periods low birthweight for African Americans was almost three
times higher and increased from 12.6 to 13.9%. There was a slight increase for whites for entry to care
in the third trimester and no prenatal care, from 3% in 1981-1985 to 3.3% in 1986-1990. For African
Americans the percentage of inadequate care rose almost 290 percent from 3.9% in 1981 to 11.2% in
1989. In 1990, the effect of several new outreach programs may be reflected by the first decrease in a
decade, as the percent dropped from 11.2 to 8.0%. (All data from California Vital Statistics tapes,
analyzed by Office for Service Integration, 1992 and 1993.)
Perinatal care resources: Through years of careful attention, the perinatal care system works relatively
well for low-income women in the County. No pregnant woman seeking care is ever turned down at
Healthy Start, the County-run Comprehensive Perinatal Services Program (CPSP) clinics. Healthy Start
includes extensive health education, nutrition,and psychosocial services. The waiting period for an initial
prenatal appointment is never longer than two weeks, a policy implemented by the Contra Costa Health
Services Department. The'Born Free Project provides regular substance abuse assessment and
interventions for all Healthy Start participants as well as women delivering at Merrithew Memorial
Hospital. The Department recognizes the vital role of prenatal outreach programs, especially in minority
communities, and supports two programs(one focusing on African-American women, in conjunction with
the East Bay Perinatal Council) that include street outreach, follow-up on broken appointments,
transportation assistance, and other support services. Staff from these programs find pregnant women
and follow them throughout their pregnancies, and after birth to ensure that their newborns receive
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pediatric care. It is after this perinatal period that the health care needs of Contra Costa's substance-
abusing women are not being met.
Access to Primary Health Care: Accessing the existing health care system in Contra Costa County is
constrained for low-income individuals and even more demanding for women with children especially
when on Medicaid or without any source of insurance. The publicly-funded health care system is over-
burdened and under-funded. As a result, long waits to get appointments and long waits in the clinic are
common. In addition, for women seeking care for themselves and their children, the additional burdens
of transportation and child care can make the trip to the doctor seem insurmountable. As a result, many
families do not have a regular physician or source. of health care and rely on emergency room care.
Health problems go unrecognized or untreated until more serious consequences result. This is especially
problematic for the substance abusing population which risks HIV/AIDS, TB, and STD infection.
It is the experience in Contra Costa that pregnant and parenting women with alcohol and drug dependence
often ignore preventive and even acute health needs when actively using and tend to continue to neglect
health care issues during the ups and downs of early recovery. Many are apprehensive about using health
care due to the attitudes, prescribing practices, and. lack of addiction medicine expertise of physicians.
Attendance at prenatal care, attention to family planning, childhood immunizations, and other aspects of
preventive and routine primary care are compromised. Often recovery is jeopardized as well.
On the other hand, treatment providers experience frustration in communicating with medical care
providers. They see that clients' recovery is often compromised by physician prescribing practices or
other physician recommendations. During the course of pre and perinatal care standard medical
treatments can increase relapse potential predictably, and should be accompanied by a coordinated
increase in recovery support. Examples include the prescription of stimulant tocolytics for preterm labor
to women with stimulant dependence; use of opioids such as demerol as obstetric analgesia in opioid and
sedative dependent women; and prescription of codeine to take home after delivery. Because of these
risks, explicit exchange of information and coordination of interventions between medical care and
substance abuse treatment is essential.
Finally, treatment programs frequently need medical consultation in many situations when serving
pregnant and parenting women and their children, including how to implement adequate bed rest,
knowing when women need to be taken for medical assessment, and understanding prescribed'
medications.
There are no specialized resources currently available to reach out to substance abusing women in
recovery programs and educate them aggressively about health care issues, preventive health,
communicable disease or to link them with health care providers. There is no organized way to acquaint
women with addiction medicine primary care providers. And there is no consistent way to provide
medical consultation to the outpatient treatment programs.
Immunizations: In 1990, 38% of children living in California were not fully immunized by age two.
In Contra Costa County, retrospective surveys conducted in 1990 of kindergarten children found that 50%
of the County's children from households with incomes less than 200% of poverty level had not been
immunized by age two. Improving childhood immunization rates has been adopted as a high priority
project by Contra Costa Health Servicds Department, which provides free and low-cost immunization
clinics throughout its Public Health system. Special outreach to substance abusing women with children
is needed because the abuse lifestyle often compromises follow-up on preventive health services for
children.
Pediatric Care: Through the U.S. Census Data, the California Health Services Department identified
49,000 Medicaid eligible children (birth-21 years) and 67,000 children from families under 200% federal
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poverty level in Contra Costa County. Of the total 116,000 children eligible for health screening and
follow-up medical services through the Contra Costa Health Services Department Child Health and
Disability Prevention Program, only 27.6% have received health screens in the past eleven months (July
1992-May 1993). (CHDP Summary-To-Date, 1993). Women enrolled in existing substance abuse
treatment programs have an average of 3.7 children apiece. Reports from these programs estimate that
only 50% of the women have a regular source of health care for themselves or their children. In
addition, access to pediatric health care services for low income families has declined over the past five
years. Currently, only 30% of pediatric providers accept new patients with MediCal. (CHDP, 1993)
Developmental Services: Children exposed in utero to alcohol or drugs, and those raised in alcohol-and
drug-involved environments are likely to suffer from a range of physical, cognitive and emotional
problems which affect their positive development. Unfortunately, existing developmental assessment and
intervention services in Contra Costa County are not sufficiently available to provide the volume and type
services appropriate for the children of substance abusing women. Existing services are limited by their
sources of funding to focusing on children with certain specific and measurable delays. Existing services
including the schools' special education programs and the State's system of services for developmentally-
delayed individuals (Regional Centers) and the Contra Costa Health Services Public Health Division's
High Risk Infant Follow-up Program. Children with "softer" signs of incipient problems remain
unrecognized and unserved until problems are severe enough to "qualify" for intervention.
The Interagency Council for Infant Services, Contra Costa's coalition of all programs serving families
and children with developmental delays and risks for delays has identified the children of substance
abusing women without severe delays as a group which is not served by the existing system. (Diana
Jorgensen, Personal Communication). According to Corkery (1992), the majority of substance-exposed
children (approximately 60%) do not show any behavioral or learning problems, while a smaller group
(approximately 30 - 40%) do have problems with keeping their attention focused, handling frustration,
and delayed language development.
In addition to the limited resources for conducting initial assessments and following children with less
severe delays,there are no resources for teaching substance abusing parents how to do infant stimulation,
or structural play for example to help their children progress. The children of women in the outpatient
treatment programs are at-risk for developmental delays because of in-utero drug and alcohol exposure
and/or because of the parents' drug-involved lifestyle. The limited training for and lack of consultation
to child care providers in the outpatient treatment programs means that the emotional issues children
experience as a result of their mothers' addictions may go unaddressed, and behavior problems handled
inappropriately. Thus the children of substance abusing women not only need different kinds of
developmental services but also child care that is developmentally appropriate and able to address the
child's recovery issues, as well.
Child Care Capacity: Options for Recovery's intensive day treatment programs, Ujima East and West,
are funded currently to provide child care for one child per women in the outpatient programs. Both
programs (two sites)attempt to accommodate small numbers of the additional children of the women who
usually have 3-4 children. The Born Free Project is able to provide child care for up to two children per
women in treatment at their three outpatient sites. The Contra Costa Child Care Council contracts with
the Born Free Project to provide child care staff to its program. However, funding limits the provisions
of child care to group counseling sessions. None is currently available for individual counseling sessions
or intake appointments.
There is an acute need for more child care capacity at outpatient treatment sites for two reasons. As
noted above, women in the outpatient treatment programs have an average of 3.7 children each. Ability
to accommodate only 1 to 2 children in child care is inadequate. Ujima East and West report that they
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cannot accommodate in child care 55 children of women participants. In addition, when programs do
stretch to include more children per women, they find themselves with poor worker to child ratios.
Dual Diagnosis: A 1986 Contra Costa County survey indicated that dually diagnosed clients comprised
a significant proportion of clients treated by mental health and substance abuse programs. Of 55 Contra
Costa County patients treated on a receiving unit at Napa State Hospital, 80% had a history of substance
abuse which had contributed to the condition leading to hospitalization. The outpatient mental health
clinic in one of the County's western region fount! that 32% of new clients referred for psychotherapy
had substance abuse problems. The County's Psychiatric Emergency (Mental Health Crisis Services)
report 50% of intake are substance abusers. Also the Jail Mental Health Services indicate 50-80% are
dual-diagnosis patients. In March 1993, 30% of Options for Recovery Project(OFR) clients self-reported
a history of psychiatric problems. OFR has scheduled a dual diagnosis prevalence study for August 1993.
The Medical Director of Mental Health reports that for the last several years there has been a 60 - 70%
incidence of substance users among the mental health population. The Contra Costa County Mental
Health budget has been reduced for all therapeutic: services in outpatient clients. Only one therapist is
assigned to each outpatient client which only serve the severely and persistently mentally ill (SPMI) adult
clients; there are no services for the dually-diagnosed clients unless they meet SPMI criteria. In addition,
all outpatient clinics must receive referrals from medical services which takes priority over dual diagnosis.
With limited funding of the County's Partial Hospital, only the SPMI client who abuses drugs can access
this service. Finally, waiting lists for the outpatient clinics have been eliminated. All clients who do not
meet the SPMI or acute crisis criteria are referred out to private resources.
Assessment of Needs: Contra Costa County faces the challenges of geographic expanse and client
cultural and racial diversity when providing services to women substance abusers and their children.
Over the past six years, the County has developed a network of services linked by a vibrant ADAPT and
creative-alliances between non-profit agencies and. the County Health Services Department for model
programs. Contra Costa County has consistently taken a planned "developmental" approach to providing
services for women substance abusers. The building of the current network of services has proceeded
incrementally, and has included developing new services, coordinating and integrating existing services,
assessing limits and gaps, and then developing additional services to meet identified gaps.
Existing services for women and children includes detoxification beads in East and West County which
serve up to 13 women at a time. A total of 55 residential recovery (and transitional) beds are available
for women and their children. An additional 156 families are served through outpatient and intensive day
treatment services. Case management and jail services, prenatal street outreach and substance abuse
prenatal and labor and delivery interventions are provided as well. In spite of the current array of
services as many as 30 women at a time are placed on waiting lists for residential programs. In addition,
the outpatient treatment services face tremendous odds in retaining women who are continuing to live in
the same environments, surrounded by the same people who supported their drug and alcohol use.
Residential programs are costly and are difficult to site. Contra Costa County has succeeded in having
five sites over the past 7 years licensed for residential services for women and children. These residential
programs are operating very effectively. Occupancy stays at 100%, virtually all the time. Retention is
high. Women are making progress in recovery. However, possible new sites for residential programs
have yet to be identified.
The WCC Project is designed to improve the network of outpatient treatment programs for women and
their children by addressing several interrelated weaknesses in the current system. Because capacity is
greater in the outpatient system, the goal is to build up its effectiveness so that waiting lists for residential
programs can be reduced. It is also consistent with Contra Costa County's philosophy of treating a
women in the context of her family and community to seek to improve the outpatient treatment system.
1n
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Retention: The existing women's outpatient treatment programs =- Options for Recovery's Ujima East
and Ujima West; Born Free's outpatient treatment services at the Richmond, Pittsburg and Martinez
Health Centers; and Living Free in West County — are challenged continually to retain women in their
services. While figures vary across programs, an estimated 92% of the women participating in them
are receiving public assistance, 90% are unemployed and between 33% and 59% are homeless. In one
program, 60% of participants are mandated by Child Protective Services and 25% by the Probation
Department. The women participants have an average of 3.7 children. The outpatient treatment
participants face instability and a host of pressures on them every day.
As noted above, mental health needs are high; development services for children are limited;
communicable diseases — HIV/AIDS, TB and STD's -- are rampant; access to primary health care for
women and children is constrained. Finally, current funding limits the outpatient programs' abilities to
provide safe and effective childcare for all of the children women have. Women without reliable sources
of alternative care for their children, do not participate regularly in treatment. Similarly, women with
untreated mental health problems are irregular attendees and are often difficult to integrate into the
structure of the treatment program. Clearly, lack of stable housing is a major threat to retention, as well.
Other resources are being identified to address this issue; thus, housing needs are not discussed in this
proposal.
The twin lacks of insufficient child development and health education and health care resources for
women and their children threaten to compromise physical health and positive development of children.
Untreated medical, communicable disease and developmental problems can derail treatment progress and
threaten the transition to and maintenance of continuing sobriety. Resources to address these needs are
important adjuncts to treatment.
Contuing Care: They are also essential ingredients to supporting continuing recovery in the community.
The area of continuing care is one where the network of services for women and their children is still
in its infancy. Each outpatient program includes a continuing care component of maintaining support for
participants once they have graduated from the intensive phase of treatment. However, all programs
identify the need for a much stronger community of recovery to support women, not only as participants
graduate from intensive treatment, but to support them during the times when the outpatient programs
are not open.
Currently, the outpatient treatment programs are staffed for operation 40 hours per week. Staff are
generally not available on weekends or during the evenings. Resources to help women during these hours
of unavailability can make the difference between relapse and continuing sobriety. Exposure to the
experience of program graduates and other women living in the community with long-term recovery can
demonstrate to women in early recovery what is possible. There is no central place for substance abusing
women in recovery to join with others like themselves to share their struggles and triumphs and to help
each other move forward.
Independent Findings: In confirmation of the findings described above, an independent evaluation of the
Options for Recovery program identified critical gaps in Contra Costa County's comprehensive treatment
system, including: continuing-care;early interventions for children with no obvious developmental delays;
mental health services; and medical services (Options Evaluation 1992). The evaluators noted that"(tjhe
most difficult clients to work�with are those that have real mental disorders, have lost their children, and
are from severely dysfunctional and abusive relationships. For many of them, intense psychotherapy is
needed."
The proposed Women's Continuum of Care Project will help to fill in many of the service gaps while
seeking to develop further the philosophy guiding Contra Costa's women's substance abuse programs of
focusing on the woman in the context of her family and community. The proposed Women's
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Continuum of Care Project will include: creating special addiction-sensitive medical services, utilizing
a family practice model to provide health care with an addiction awareness for the entire family;
increasing the amount of child care available and providing childcare services with a developmental and
parenting focus; enhancing developmental services for children of substance abusing women; enhancing
services for dually diagnosed women; and establishing a Community Recovery and Resource Center
which will utilize a social model to create a central place where women in recovery can volunteer to help
other women and where continuing care based in the community can be readily accessible.
Description of Data Sources
The Contra Costa Health Services Department has extensive data collection capabilities and reporting
responsibilities. The Contra Costa Health Services Department Office for Service Integration conducts
periodic analysis of the California Vital Statistics data tapes in order to track birth and infant mortality
trends. The Contra Costa Health Plan and Community Substance Abuse Services collect utilization and
quality assurance information for their respective services. All Community Substance Abuse Services
programs and contract agencies complete California Alcohol and Drug Data System forms which are
analyzed at the State level. CHDP compiles monthly data on the number of referrals, overall visits,
health screens, and medical and dental referrals for follow-up.
The Communicable Disease Division and the HIV/AIDS Program produce quarterly reports containing
recent testing data analysis and specific transmission or seroprevalence data for critical populations.
Diagnosed AIDS cases are reported and recorded at the county level, analyzed by the State HIV/AIDS
Epidemiology Branch for-Quarterly Reports. California Department of Health Services conducts an
annual study of anonymous blood specimens from .all infants born in a three-month period.
The Alcohol, Drug Abuse, and Perinatal Task Force of Contra Costa County (ADAPT) conducts a bi-
annual survey of treatment providers regarding the: number of pregnant and parenting women served,
number of children served, and women on the waiting list. The Health Services Department Options for
Recovery conducted a limited chart review in March, 1993. Annual evaluation reports on the Born Free
Project include demographics, service utilization and treatment outcomes.
C. GOALS AND OBJECTIVES
Recent and ongoing evaluations of the network of outpatient services for women have identified critical
service gaps which render treatment inadequate for many of the women and children who most need
assistance. The Women's Continuum of Care Project will enhance existing services and address the
current gaps, resulting in an expanded knowledge of the interventions necessary to have the greatest
impact on improving treatment outcomes for substance abusing women and their children.
The goals and objectives below respond very specifically to the gaps in an already complex, multi-faceted
service delivery system. (See Appendix IV, Document 6, Map A for map of full service delivery
system.) (See Map C for illustratin of how WCC:3ervices are integrated into the existing outpatient
system.)
Goal 1: Improve the gverall health of a minimum of 147 women substance abusers and their
families by providing enhanced health screening and medical services.
Objective 1.1: Provide health assessment, screening, and liaison to medical services, testing for
communicable diseases, health education, and nutrition education and consultation on
medical issues and resources to at least 147 program participants and their children at six
women's outpatient treatment sites, the Pittsburg Pre-School nursery for substance-
exposed infants and the pilot "Community Recovery Resource Center."
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Objective 1.2: Designate weekly Family Practice Clinics with a Chemical Dependency focus in East,
Central and West County, providing 1800 visits for women substance abusers and their
families per year. (36 visits per week.)
Goal 2: Improve the child development outcomes for at least 200 children.
Objective 2.1: Assess the developmental status of a minimum of 200 children of women in recovery,
provide ongoing monitoring,parent teaching and case consultation to treatment providers
and involved caregivers, and establish a referral process with existing developmental
program for those children in need of more intense services.
Objective 2.2: Develop a child enrichment curriculum, including infant stimulation, play therapy,
assessment and monitoring for use at the participating outpatient treatment programs.
Objective 2.3: Train existing and new child care staff as they are added to use the child enrichment
curriculum so that developmentally-appropriate child care services and child recovery-
oriented child care are provided to at least 200 children at the treatment sites.
Objective 2.4: Contract with Contra Costa Child Care Council to assist in recruiting and training
additional child care staff for treatment sites; and to identify new funds to providing
ongoing support for increased capacity of on-site developmentally-appropriate child care
at the treatment sites.
Objective 2.5: Increase the child care capacity of the outpatient treatment programs and create capacity
at the CRRC by hiring additional child care workers to provide developmentally-
appropriate child care at the participating programs.
Goal 3: Reduce substance dependency among women with dual diagnosis
..Objective 3.1: Train Family Practice Health Physicians in working with women who are dually-
diagnosed. Provide ongoing consultation and support to Physicians.
Objective 3.2: Train six outpatient treatment programs to conduct initial mental health screening of
women entering services to identify those in need for further assessment and possible
mental health services.
Objective 3.3: Provide in-depth assessment services for a minimum of 50 women substance abusers in
treatment who have multiple needs. Assist treatment providers to tailor substance abuse
treatment plans to address mental health needs.
Objective 3.4: Arrange for dual-diagnosis services including medication, crisis intervention, brief
hospitalization and ongoing monitoring and evaluation as well as referrals to other more
specialized providers for identified dual-diagnosis participants.
Objective 3.5: Provide mental health sessions (in-home or at the treatment site), a maximum of twice
a week, to a minimum'of 5 dually-diagnosed women substance abusers,.per year.
Goal 4: Improve treatment outcomes and retention for women substance abusers by
enhancing continuing-care services.
Objective 4.1: Develop a Pilot "Community Recovery Resource Center" (CRRC) in East County for
women substance abusers and their families. Offer such activities as support groups,
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twelve step groups, child care, life skills classes, continuing education, and vocational
training.
Objective 4.2: Implement an active volunteer component at the CRRC which is community-based,
culturally relevant, woman-centered, and incorporates the "Twelve Step" tradition of
service.
Goal 5: Expand the knowledge base regarding which interventions or array of interventions
have the greatest impact on improving treatment outcomes for women substance
abusers and their families.
Objective 5.1: Implement a comprehensive process and outcome evaluation of the WCC Project, by
enhancing an already extensive data collection system. Provide findings to WCC
Executive Committee and CSAT.
D. APPROACH AND METHODS
Project Mission and Treatment Philosophy. n.e overall philosophy of the Women's Continuum of
Care Project (WCC Project) is broad-based, focusing on the particular needs and circumstances faced
by women in connection to their own lives, their families lives, and the community around them. The
WCC Project recognizes that the issues which women experience in their addiction are the same
challenges throughout their recovery.These issues include low self-esteem; extreme stigmatization; a high
probability of sexual abuse; lack of social support.; the need for child care; the need for services which
accommodate women's physical and mental health needs; and services which accommodate their
children's developmental needs.
The WCC Project takes the next step in the evolution of Contra Costa County's model substance abuse
service delivery system for women. Two broad strategies are being proposed. The first is to enhance
the resources of the current outpatient treatment providers—to make them more comprehensive, and thus
more effective in helping women to recovery. Rmources to be added which the six women's-specific
outpatient treatment programs will draw upon include: 1. linkage to primary medical services with an
addiction focus; 2. health education and screening; for communicable diseases, nutrition education and
childhood immunization education and provision;3. developmental assessment, referral, and intervention
services; 4. increased child care capacity and enrichment of child care services to be developmentally
appropriate for substance-exposed children; and 5. dual diagnosis training, consulting, assessment, and
counseling services. The addition of these services to the existing women's outpatient programs will
improve treatment outcomes by closing the gaps which currently threaten women's ability to succeed.
The second broad strategy is to extend the effectiveness of the current outpatient treatment programs by
creating and testing the effectiveness of a Community Recovery Resource Center (CRRC). The CRRC
function is a-drop-in center where women in treatment programs, their children, and significant others
can have a place to gather to continue their recovery activities. In this capacity, the CRRC extends the
treatment milieu into the community, providing a place for women and family-oriented groups and
activities to take place. This resource is especially necessary to provide a context for continuing
community-based recovery activities. Volunteer/participant involvement in creating the activities which
will go on at the CRRC is crucial to the model. This is one key means by which women in treatment
become linked into a healthier recovering community; her children, and extended family are included;
and the larger community of recovering people is engaged in extending the effectiveness of the formal
treatment programs.
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One CRRC will be created and located in East County, the area of the County with the fewest resources
for recovering women. (In addition, another CSAT proposal from Contra Costa County is proposing a
somewhat similar pilot project to be located in West County.)
The WCC Project is designed to enhance primary health care service delivery and reduce the incidence
of TB, HIV, and other STDs among women substance abusers and their families; address the special
needs of dually-diagnosed women presenting for substance abuse treatment; minimize the negative impact
of substance abuse upon the children of women substance abusers; and improve treatment outcomes and
retention for women substance abusers by strengthening early engagement and after-care recovery
services.
As an enhancement to Contra Costa County's current service delivery system for women substance
abusers and their families, the WCC Project shares a mixed social/medical model approach to treating
chemical dependency. This is an adapted perinatal substance abuse model which is named the "Family
Recovery Model". The model's holistic approach acknowledges that the individual woman's recovery is
rooted in the health and recovery of the family and larger community.
Through this model, the project seeks to promote family stability and therefore addresses the needs not
only of the woman, but also her children and family. There is strong emphasis on families and
communities. They play a pivotal role, noting that in they may supporting or threatening the woman's
recovery.
This approach is intended to foster self-esteem and independence. The Twelve Steps are an integral part
of the model. Because of the strong family health and mental health and child development components,
this social model of recovery is combined with the medical areas of child development, psychiatric
assessment, and the provision of primary health care.
Identification & Engagement Procedures
Identification: Six Outpatient Treatment Sites
The WCC Project is designed to enhance a.multi-faceted treatment delivery system. The Project will
extend services to program participants throughout six of Contra Costa's outpatient treatment programs
serving women with children including Ujima East and the Born Free Project in East County; The Born
Free Project in Central County; and Ujima West, Living Free, and the Born Free Project in West
County. In addition,.appropriate services, such as the health education and child development services,
will be made available to children enrolled in Pittsburg Prschool's Therapeutic Nursery and their mothers.
The participating programs named above have been full partners in the design of the proposed WCC
Project. Once notification of positive review and funding is received, the Project Director will convene
an in-depth working meeting with the providers to review the newly available services•and agree on
procedures for gaining access to them. As a result of this session, the Project Coordinator will develop
and conduct an orientation training for treatment program staffs which will review such topics as the new
resources available, procedures for obtaining access, additional documentation requirements, etc. This
training will be offered oil a semi-annual basis to ensure that new treatment staff will become
knowledgeable aboutcomprehensive services.
Once in place, the WCC: Project will rely upon the participating providers to identify their program
participants in need of the- new services available. This assessment and tracking of results will be
incorporated into each provider's intake and assessment procedures and each program participant's
substance abuse treatment plan.
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Intake and Assessment. Client eligibility for participation in the WCC Project services will be assessed
on the following criteria which are those used by the six participating outpatient treatment programs: 1)
Woman resides in Contra Costa County; 2) Woman is alcohol or drug-dependent (DSM III-R criteria);
3) Woman is pregnant, postpartum or parenting; children under the age of 10 (regardless of age of
mother—teen mothers will be welcomed); and 4) Woman desires recovery services.
As noted above, use of WCC services will be: through outpatient treatment programs who do not
currently have the resources to offer the specialized services being sought by this proposal. The intake
and assessment forms provided in Appendix VII are the forms currently used by the outpatient programs
proposed for participation in the WCC project. All children at the Pittsburg Pre-school's Therapeutic
Nursery will be eligible for child development services.
Treatment Modalities and Improvement
Enhanced Health Care: The WCC Project proposes to link together substance abuse treatment with
health care by enhancing the current health care delivery system for women substance abusers and their
families. This enhancement will incorporate three tiers of service including: health and nutrition
education; health screening, testing, and immunizations; and improved access for patients and treatment
providers to primary health care through development of Family Practice Clinics with a chemical
dependency focus within the existing Department of Health Services, Hospital and Clinics system.
Public Health Nurses, knowledgeable in addictive medicine and communicable diseases, will be identified
by the Project to provide health education, screening, testing, and immunizations at the seven outpatient
treatment programs and the CRC, and to serve as liaison for health care needs between clients, treatment
providers, and medical care providers. This model will provide a simple point of entry for women and
their families; increasing the likelihood that they will establish a.regular source of health care and use it
appropriately. The PHN's will be assisted by two Public Health Aides. In addition, Cooperative
Extensions's Expanded Food and Nutrition Education Program will assist with the nutrition education
component.
Health Education and Nutrition Education: The Public Health Nurses will offer monthly health
education workshops at each of the six outpatient treatment programs, the Pittsburg Pre-school
Coordinating Council Nursery and the CRRC. (,See Appendix VIII, Document 10) This information
will be presented in a positive, non-threatening, and non-punitive manner. Workshop topics will address
such topics as the physiological impact of drug and alcohol use on women and children; preventive
medicine for both children and adults; family planning, including reproductive health education;
communicable diseases including HIV, TB, and STD; sexuality; nutrition; parenting and child
development; and how to access health services.
Health Screening and Testing: Public Health Nurses and Public Health Aides: Preliminary health
screening and testing will be conducted at the participating sites. The outpatient treatment providers will
furnish program participant's health and psychosocial assessments to the-PHN for review. Following this
review, the PHN will conduct appropriate health screenings with the women and significant family
members including testing for high blood pressure, hepatitis, signs of pre-term labor, TB, anemia, HIV,
and other STD's. The PHN#will refer the families to the Chemical Dependency Family Practice Clinics
for their test results and follow-up care, and encourage establishing a regular source of health care. The
PHN will also review and discuss the children's health with the women and provide a preliminary
pediatric exam, assessing their overall health needs and recommend appropriate follow-up. When
appropriate, the PHN will give the children immunization shots. In addition, referrals will be made to
related services such as the Women, Infants and Children (WIC) Program, and the Child Health and
Disability Program (CHDP). The Public Health Aides will assist the PHN's in their activities and
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particularly with follow-up of women to assure entry into a regular source of care and use of
recommended services.
Primary Health Care: Family Practice Health Clinics: At the conclusion of the health assessment and
screening, the PHN will refer the women and their families to the Public Health Aide assigned to oversee
scheduling of the three specialized Family Practice Clinics.
Twelve slots in each of three weekly Family Practice Clinics will be designated in East, Central, and
West County for participants in the WCC network of services. The clinics will be staffed by Family
Practice Physicians specializing in addiction medicine. Three Family Practice Physicians have agreed
to staff these clinics, two of whom have nine years experience in the development of perinatal addiction
services and are certified by the American Society on Addiction Medicine. Two of these Physicians are
female, and all are experienced in working with and sensitive to the needs of low-income women and
their children.
The Family Practice Clinics offer a full range of primary health care services including comprehensive
physical examinations and ongoing care for adults and children, gynecological exams, prenatal,
postpartum, family planning, pregnancy testing, treating urinary and vaginal infections, well adult, well
child, pulmonary cardiac disease, outpatient detoxification, prescribing of agents such as antibuse, as
needed, ongoing mental health management (see below for more details), and HIV care. In addition,
coordination of any specialty medical services will be done by the Family Practice Physician.
The team of family practice physicians will be assisted by a pediatrician with addiction medicine expertise
as well as the psychiatrist and psychiatric clinical nurse specialist whose activities are described in greater
detail under "dual diagnosis" below. This team will develop protocols for primary family health care of
pregnant and parenting women with alcohol and drug dependency and their families, implement the
protocols in the designated clinics, and serve as vehicles for implementation of protocols throughout the
health department. One physician will coordinate implementation.
This enhancement of direct medical services will be at no cost to the grant project, however the grant will
budget physician hours for protocol development, system implementation, and multidisciplinary case
conferences at treatment sites.
It is possible to create these Family Practice Clinics at this time with a chemical dependency because the
Health Services Department is in the process of expanding capacity in order to assume greater
responsibility for managing the care of Medicaid beneficiaries in Contra Costa County. The State of
California is seeking to control costs and expand access to primary health care for Medicaid beneficiaries
by shifting to a managed care system. Contra Costa County's, Contra Costa Health Plan has over 20
years of experience as a publicly-sponsored,federally-qualified HMO. This experience has led the State
to encourage Contra Costa County to move as quickly as possible to assume responsibility for managing
the care of at least 60% of the AFDC and medically-indigent children population. This expansion
combined with the Health Services Department's commitment to integrating services (family practice
medical care, substance abuse services, and mental health) will make it possible for women and their
families to enroll in an integrated system of family-oriented, addiction-sensitive health care services.
Enhanced Child Development and Child Care Services: The WCC Project proposes to improve child.
development outcomes for the children through the enhancement of child care services at current
treatment sites and the provision of child development assessment services. Unfortunately, many children
of substance abusing women in Contra Costa County do not exhibit developmental delays at a level which
qualifies them for the existing services funded either through the schools' special education programs or
the State's system of services for developmentally delayed individuals (Regional Centers). As a result,
many children go unassessed and unmonitored until problems become severe enough to "qualify" for
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intervention. The WCC Project will employ a full-time Child Development Specialist to help these
children. The Child Development Specialist will assess and monitor children who are at-risk or appear
to be experiencing developmental problems. The Specialist will develop a Child Enrichment Curriculum
to train treatment providers' child care staff on assessing and addressing children's developmental and
recovery needs. The Specialist will also act as a liaison with the existing child development intervention
programs to ensure that children with the more severe problems which qualify them for intervention
services are enrolled and followed appropriately.
The WCC Project will contract with the Contra Costa County Child Care Council to enhance
developmentally-based childcare services at the treatment programs. The Council, experienced in
establishing and assessing quality child care, will assist the treatment programs and the CRRC to recruit,
train child care staff to provide services in the treatment programs and at the CRRC. They will include
existing child care staff in training activities as part of programs skills update responsibilities. The
Council will also develop new funding sources to support the continuation of the enriched child care
services at the participating programs. Along with increasing child serving capacity comes the need to
provide sufficient resources for the children, including cribs, toys, blankets, etc. Funds will be budgeted
for this need.
Enhanced Services to Women with Dual-Diagnosis: Increasingly, women are presenting themselves for
treatment who are suffering from both mental health disorders and substance abuse; treatment programs
are not trained to serve them effectively. The WCC Project begins to address this critical need by
providing clinical assessment, training, and consultation services; acute care and pharmacotherapy
interventions; and mental health counseling services.
This component of the WCC Project will be provided with the services of a Psychiatrist (provided in-
kind), and a Psychiatric Clinical Nurse Specialist, both of whom are trained and experienced in addiction
medicine.
The Psychiatrist will train the Family Practice Physicians to work with dually-diagnosed women. This
training will include information regarding assessment, medication, and long-term care. At the
conclusion of this training, the Psychiatrist will offer ongoing consultation to the Physicians and will
schedule case consultation sessions with the doctors, treatment providers, the Psychiatric Clinical Nurse
Specialist, on an as needed basis. In addition, the Psychiatrist& Clinical Nurse Specialist will train six
outpatient treatment programs to conduct initial mental health assessments of women entering their
programs.
Once trained, the treatment providers will conduct initial mental health assessments, and if the findings
indicate a dual-diagnosis, contact the Clinical Nurse Specialist for a more in-depth assessment and
treatment recommendation. The Psychiatrist will supervise the Clinical Nurse Specialist and consult with
the Family Practice Physicians so that further assessment, and appropriate treatment planning is carried
out. The Clinical Nurse Specialist will assist with crisis interventions, coordinate referral for brief
hospitalizations, and necessary follow up of the dually-diagnosed women substance abusers. . As
appropriate, the Clinical Nurse Specialist may provide mental health counseling and/or assist treatment
providers to tailor substance abuse treatment plans to address mental health.needs.
Enhanced Continuing-Care: Community Recovery and Resource Center. The WCC Project proposes
to establish a pilot Community Recovery and Resource Center (CRRQ in East County. The CRRC is
designed to provide women in intensive day treatment, a drug-free environment in the community during
the late afternoon, evening, and weekend hours; and provide women in later recovery, continuing access
to a drug-free supportive and fun environment. The ultimate goal of the CRRC is to build a supportive
community among women substance abusers in recovery and their families. The Center will be housed
at Centurion Plaza, an East County location which currently hosts a number of critical service providers
Mary Foran, California
Chuck Deutschman, California
including Occupational Rehabilitation Services, Head Start, Options for Recovery's Case Management
services and Ujima East Intensive Day Treatment Center, PATHS, a homelessness prevention project,
as well as Case Management for pregnant and parenting teens. The Pittsburg Health Center is only
several blocks away. The site is easily accessible by public transportation.
Health Services Lease Management has contacted the owner and space is available. The property is a
competitive rental commercial space. We are currently renting property for Ujima East and OFR Case
Management at the Centurion Plaza. Because the property is in a commercial, rather than residential
area, no change of use is required. The City of Pittsburg is notified when Health Services leases space
for programs. Approval was granted routinely when Centurion Plaza space was leased for the above-
named programs. We do no anticipate any barriers to concluding a lease agreement for the Community
Recovery Resource Center.
The CRRC will offer essential health and human services on-site such as child care; children's recovery
groups; health education and testing for communicable diseases; Twelve Step groups (eg AA, NA, IA),
family violence services; parent support groups, vocational rehabilitation services; GED assistance;
financial and daily living skills training; housing assistance; services to support and enhance self-esteem,
and transportation coordination. (See Appendix VIII, Document 11 for proposed CRRC schedule)
The Health Services Department will subcontract administration of the CRRC out through a competitive
bid process. The chosen service provider will be responsible for establishing and operating the Center.
The CRC will be open seven days a week between the hours of 4-10 pm and will be staffed by a full-time
Site/Volunteer Coordinator, Childcare Coordinator, and a team of volunteers; all of whom have been in
recovery for at least two years or more and understand the challenges facing women in recovery. Priority
will be placed on recruiting volunteers reflecting the cultural communities comprising East County's
service population.
The SiteNolunteer Coordinator will be responsible for overseeing day to day operation of the CRRC,
ensuring that a comprehensive array of services will be offered through volunteers and service providers.
The Coordinator will recruit women to help lead support groups and organize self-initiated activities.
These activities will, in large part, be coordinated by program participants. This volunteer opportunity
will enable women in recovery to practice the Twelve-Step Tradition of service; giving back what one
receives.
The Child Care Coordinator will provide developmentally appropriate child care services at the CRRC
and train volunteers to provide same to cover most of the CRRC hours. The safe and sober supportive
environment existent at the Center combined with developmentally appropriate childcare will enhance the
existing service delivery system and support women's efforts to maintain a drug-free lifestyle. The Child
Care Council will assist the Child Care Coordinator with the volunteer recruitment and training.
Linkages. The WCC Project requires that close and cooperative working relationships exist among the
key project collaborators: Born Free, Tri-County Women's Recovery Services (Ujima East and West),
Living Free, Pittsburg Pre-School Coordinating Council, Contra Costa County Child Care Council, the
Children's Bureau of the Social Service Department, and within the Health Services Department, the
Community Substance Abuse Services Division, Office of Service Integration (which includes
Comprehensive Perinatal Services Program, Options for Recovery, Comprehensive Perinatal Outreach,
and Prenatal Care Guidance Program), Mental Health Division, Public Health and Hospital and Clinics.
There must be effective collaboration and coordination at both the management level and the service
delivery level if the project is to succeed.
The process of developing the WCC Project service system described in this proposal demonstrates the
collaborative alliances already in place in Contra Costa County. The Alcohol and Drug Abuse Perinatal
Mary Foran, California
Chuck Deutschman, California
Task Force (ADAPT) in existence since 1987, devoted two meetings to reviewing and providing input
to the WCC program plan. Decision-makers from all participating programs met several times to design
the program and work out the specific proposed characteristics.
All participating programs participate regularly in the policy and program development activities of
ADAPT and all, except Living Free and the Pittsburg Pre-School Coordinating Council, currently meet
monthly as the Options for Recovery Steering Committee to address the details of that program's ongoing
implementation and evaluation. (See Appendix I.1, Document 5 for the letters of commitment from
all agencies to participate in and carry out the WCC Project.)
Cultural Legitimacy. Contra Costa County has long been committed to creating a service delivery
system which is responsive to the needs of all of its residents. This commitment has been expressed
through the utilization of a model checklist for the examination of cultural competence in social service
agencies developed by Dana, Behn and Gonwa; development of county-wide cultural awareness trainings;
priority on hiring staff from diverse cultural communities; and incorporation of cultural traditions and
sensibilities into service provision.
Cultural Competence Checklist. Contra Costa County substance abuse treatment providers serving
women and their children employ a checklist, developed by Dana, Behn, and Gonwa, to help assess and
evaluate cultural competency within their programs. This checklist reviews the practices, services,
culture-specific services, relationship to community, training, and evaluation practices used by each
provider. (See Appendix VIII, Document 10) This assessment mandates that each agency evaluate their
services from the perspective of a diverse service population and respond to shortcomings within their
programs. It is recognized that cultural competence includes an ability to provide services that are
perceived as legitimate for problems experienced by culturally diverse persons.
Trainings. The Contra Costa County Training Institute, a county training resource, provides cultural
diversity training for all county employees on a regular basis. The Community Substance Abuse
Services, (the Health Services Department's Substance Abuse Division), provides periodic day long
trainings on cultural diversity to all substance abuse providers and also provides trainings specific to
women in recovery, focusing on the culture of women. The Born Free and Options for Recovery
Programs have held dialogues on cultural competency, inviting all staff members and friends to attend
and contribute to an ongoing discussion regarding cultural competence. In addition, Options for Recovery
is planning to hold a series of trainings that will enable OFR staff to more effectively serve the diverse
and specific populations seeking treatment. The East Bay Perinatal Council developed a training on Afro-
centricity, creating a greater appreciation and understanding of the African American culture and
traditions and its impact upon service and individual recovery. ADAPT hosts dialogues on cultural
competency among perinatal substance services. The Office of Service Integration, the WCC Project's
lead agency, has focused on cultural competency w the topic of various staff meetings. And the Heritage
Project, Contra Costa County's specialized foster care services has developed a culturally competent
curriculum to train the foster care parents and relatives.
Staff Diversity. Contra Costa County substance abuse treatment providers serving women and their
children employ a staff which is representative of the population that it serves. A majority of the staff
are women who have been in recovery, and who reflect the cultural diversity of Contra Costa County's
population.
Cultural Traditions. In addition to hiring staff representative of the cultures served and training all staff
on understanding and appreciating cultural differences, Contra Costa County providers are developing
greater awareness of cultural differences and providing women-centered treatment with appropriate
respect. For example, providers have developed an understanding of pregnancy rituals and family raising
customs. The programs have begun to incorporate the use of ceremonies, rituals, and special events from
Mary Foran, California
Chuck Deutschman, California
One CRRC will be created and located in East County, the area of the County with the fewest resources
for recovering women. (In addition, another CSAT proposal from Contra Costa County is proposing a
somewhat similar pilot project to be located in West County.)
The WCC Project is designed to enhance primary health care service delivery and reduce the incidence
of TB, HIV, and other STDs among women substance abusers and their families; address the special
needs of dually-diagnosed women presenting for substance abuse treatment; minimize the negative impact
of substance abuse upon the children of women substance abusers; and improve treatment outcomes and
retention for women substance abusers by strengthening early engagement and after-care recovery
services.
As an enhancement to Contra Costa County's current service delivery system for women substance
abusers and their families, the WCC Project shares a mixed social/medical model approach to treating
chemical dependency. This is an adapted perinatal substance abuse model which is named the "Family
Recovery Model". The model's holistic approach acknowledges that the individual woman's recovery is
rooted in the health and recovery of the family and larger community.
Through this model, the project seeks to promote family stability and therefore addresses the needs not
only of the woman, but also her children and family. There is strong emphasis on families and
communities. They play a pivotal role, noting that in they may supporting or threatening the woman's
recovery.
This approach is intended to foster self-esteem and independence. The Twelve Steps are an integral part
of the model. Because of the strong family health and mental health and child development components,
this social model of recovery is combined with the medical areas of child development, psychiatric
assessment, and the provision of primary health care.
IdentiFication & Engagement Procedures
Identification: Six Outpatient Treatment Sites
The WCC Project is designed to enhance a multi-faceted treatment delivery system. The Project will
extend services to program participants throughout six of Contra Costa's outpatient treatment programs
serving women with children including Ujima East and the Born Free Project in East County; The Born
Free Project in Central County; and Ujima West, Living Free,. and the Born Free Project in West
County. In addition, appropriate services, such as the health education and child development services,
will be made available to children enrolled in Pittsburg Prschool's Therapeutic Nursery and their mothers.
The participating programs named above have been full partnersin the design of the proposed WCC
Project. Once notification of positive review and funding is received, the Project Director will convene
an in-depth working meeting with the providers to review the newly available services-and agree on
procedures for gaining access to them. As a result of this session, the Project Coordinator will develop
and conduct an orientation training for treatment program staffs which will review such topics as the new
resources available, procedures for obtaining access, additional documentation requirements, etc. This
training will be offered on a semi-annual basis to ensure that new treatment staff will become
knowledgeable about comprehensive services.
Once in place, the WCC Project will rely upon the participating providers to identify their program
participants in need of the new services available. This assessment and tracking of results will be
incorporated into each provider's intake and assessment procedures and each program participant's
substance abuse treatment plan.
Mary Foran, California
Chuck Deutschman, California
Intake and Assessment. Client eligibility for participation in the WCC Project services will be assessed
on the following criteria which are those used by the six participating outpatient treatment programs: 1)
Woman resides in Contra Costa County; 2) Woman is alcohol or drug-dependent (DSM III-R criteria);
3) Woman is pregnant, postpartum or parenting children under the age of 10 (regardless of age of
mother—teen mothers will be welcomed); and 4) Woman desires recovery services.
As noted above, use of WCC services will be through outpatient treatment programs who do not
currently have the resources to offer the specialized services being sought by this proposal. The intake
and assessment forms provided in Appendix VII are the forms currently used by the outpatient programs
proposed for participation in the WCC project. All children at the Pittsburg Pre-school's Therapeutic
Nursery will be eligible for child development services.
Treatment Modalities and Improvement
Enhanced Health Care: The WCC Project proposes to link together substance abuse treatment with
health care by enhancing the current health care delivery system for women substance abusers and their
families. This enhancement will incorporate three tiers of service including: health and nutrition
education; health screening, testing, and immunizations; and improved access for patients and treatment
providers to primary health care through development of Family Practice Clinics with a chemical
dependency focus within the existing Department of Health Services, Hospital and Clinics system.
Public Health Nurses, knowledgeable in addictive medicine and communicable diseases., will be identified
by the Project to provide health education, screening, testing, and immunizations at the seven outpatient
treatment programs and the CRC, and to serve as liaison for health care needs between clients, treatment
providers, and medical care providers. This model will provide a simple point of entry for women and
their families; increasing.the likelihood that they will establish a regular source of health care and use it
appropriately. The PHN's will be assisted by two Public Health Aides. In addition, Cooperative
Extensions's Expanded Food and Nutrition Education Program will assist with the nutrition education
component.
Health Education and Nutrition Education: The Public Health Nurses will offer monthly health
education workshops at each of the six outpatient treatment programs, the Pittsburg Pre-school
Coordinating Council Nursery and the CRRC. (See Appendix VIII, Document 10) This information
will be presented in a positive, non-threatening, and non-punitive manner. Workshop topics will address
such topics as the physiological impact of drug and alcohol use on women and children; preventive
medicine for both children and adults; family planning, including reproductive health education;
communicable diseases including HIV, TB, and STD; sexuality; nutrition; parenting and child
development; and how to access health services.
Health Screening and Testing: Public Health Nurses and Public Health Aides: Preliminary health
screening and testing will be conducted at the participating sites. The outpatient treatment providers will
furnish program participant's health and psychosocial assessments to the PHN for review. Following this
review, the PHN will conduct appropriate health screenings with the women and significant family
members including testing for high blood pressure, hepatitis, signs of pre-term labor, TB, anemia, HIV,
and other STD's. The PHN will refer the families to the Chemical Dependency Family Practice Clinics
for their test results and follow-up care, and encourage establishing a regular source of health care. The
PHN will also review and discuss the children's health with the women and provide a preliminary
pediatric exam, assessing their overall health needs and recommend appropriate follow-up. When
appropriate, the PHN will give the children immunization shots. In addition, referrals will be made to
related services such as the Women, Infants and Children (WIC) Program, and the Child Health and
Disability Program (CHDP). The Public Health Aides will assist the PHN's in their activities and
16
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Chuck Deutschman, California
particularly with follow-up of women to assure entry into a regular source of care and use of
recommended services.
Primary Health Care: Family Practice Health Clinics: At the conclusion of the health assessment and
screening, the PHN will refer the women and their families to the Public Health Aide assigned to oversee
scheduling of the three specialized Family Practice Clinics.
Twelve slots in each of three weekly Family Practice Clinics will be designated in East, Central, and
West County for participants in the WCC network of services. The clinics will be staffed by Family
Practice Physicians specializing in addiction medicine. Three Family Practice Physicians have agreed
to staff these clinics, two of whom have nine years experience in the development of perinatal addiction
services and are certified by the American Society on Addiction Medicine. Two of these Physicians are
female, and all are experienced in working with and sensitive to the needs of low-income women and
their children.
The Family Practice Clinics offer a full range of primary health care services including comprehensive
physical examinations and ongoing care for adults and children, gynecological exams, prenatal,
postpartum, family planning, pregnancy testing, treating urinary and vaginal infections, well adult, well
child, pulmonary cardiac disease, outpatient detoxification, prescribing of agents such as antibuse, as
needed, ongoing mental health management (see below for more details), and HIV care. In addition,
coordination of any specialty medical services will be done by the Family Practice Physician.
The team of family practice physicians will be assisted by a pediatrician with addiction medicine expertise
as well as the psychiatrist and psychiatric clinical nurse specialist whose activities are described in greater
detail under "dual diagnosis" below. This team will develop protocols for primary family health care of
pregnant and parenting women with alcohol and drug dependency and their families, implement the
protocols in the designated clinics, and serve as vehicles for implementation of protocols throughout the
health department. One physician will coordinate implementation.
This enhancement of direct medical services will be at no cost to the grant project, however the grant will
budget physician hours for protocol development, system implementation, and multidisciplinary case
conferences at treatment sites.
It is possible to create these Family Practice Clinics at this time with a chemical dependency because the
Health Services Department is in the process of expanding capacity in order to assume greater
responsibility for managing the care of Medicaid beneficiaries in Contra Costa County. The State of
California is seeking to control costs and expand access to primary health care for Medicaid beneficiaries
by shifting to a managed care system. Contra Costa County's, Contra Costa Health Plan has over 20
years of experience as a publicly-sponsored,federally-qualified HMO. This experience has led the State
to encourage Contra Costa County to move as quickly as possible to assume responsibility for managing
the care of at least 60% of the AFDC and medically-indigent children population. This expansion
combined with the Health Services Department's commitment to integrating services (family practice
medical care, substance abuse services, and mental health) will make it possible for women and their
families to enroll in an integrated system of family-oriented, addiction-sensitive health care services.
Enhanced Child Development and Child Care Services: The WCC Project proposes to improve child
development outcomes for the children through the enhancement of child care services at current
treatment sites and the provision of child development assessment services. Unfortunately, many children
of substance abusing women in Contra Costa County do not exhibit developmental delays at a level which
qualifies them for the existing services funded either through the schools' special education programs or
the State's system of services for developmentally delayed individuals (Regional Centers). As a result,
many children go unassessed and unmonitored until problems become severe enough to "qualify" for
Maiy Foran, California
Chuck Deutschman, California
intervention. The WCC Project will employ a tull-time Child Development Specialist to help these
children. The Child Development Specialist will assess and monitor children who are at-risk or appear
to be experiencing developmental problems. The Specialist will develop a Child Enrichment Curriculum
to train treatment providers' child care staff on assessing and addressing children's developmental and
recovery needs. The Specialist will also act as a liaison with the existing child development intervention
programs to ensure that children with the more severe problems which qualify them for intervention
services are enrolled and followed appropriately.
The WCC Project will contract with the Contra Costa County Child Care Council to enhance
developmentally-based childcare services at the treatment programs. The Council, experienced in
establishing and assessing quality child care, will assist the treatment programs and the CRRC to recruit,
train child care staff to provide services in the treatment programs and at the CRRC. They will include
existing child care staff in training activities as part of programs skills update responsibilities. The
Council will also develop new funding sources to support the continuation of the enriched child care
services at the participating programs. Along with increasing child serving capacity comes the need to
provide sufficient resources for the children, including cribs, toys, blankets, etc. Funds will be budgeted
for this need.
Enhanced Services to Women with Dual-Diagnosis: Increasingly, women are presenting themselves for
treatment who are suffering from both mental health disorders and substance abuse; treatment programs
are not trained to serve them effectively. The WCC Project begins to address this critical need by
providing clinical assessment, training, and consultation services; acute care and pharmacotherapy
interventions; and mental Health counseling services.
This component of the WCC Project will be provided with the services of a Psychiatrist (provided in-
kind), and a Psychiatric Clinical Nurse Specialist, both of whom are trained and experienced in addiction
medicine.
The Psychiatrist will train the Family Practice Physicians to work with dually-diagnosed women. This
training will include information regarding assessment, medication, and long-term care. At the
conclusion of this training, the Psychiatrist will offer ongoing consultation to the Physicians and will
schedule case consultation sessions with the doctors, treatment providers, the Psychiatric Clinical Nurse
Specialist, on an as needed basis. In addition, the Psychiatrist& Clinical Nurse Specialist will train six
outpatient treatment programs to conduct initial mental health assessments of women entering their
programs.
Once trained, the treatment providers will conduct initial mental health assessments, and if the findings
indicate a dual-diagnosis, contact the Clinical Nurse Specialist for a more in-depth assessment and
treatment recommendation. The Psychiatrist will supervise the Clinical Nurse Specialist and consult with
the Family Practice Physicians so that further assessment, and appropriate treatment planning is carried
out. The Clinical Nurse Specialist will assist with crisis interventions, coordinate referral for brief
hospitalizations, and necessary follow up of the; dually-diagnosed women substance abusers. As
appropriate, the Clinical Nurse Specialist may provide mental health counseling and/or assist treatment
providers to tailor substance abuse treatment plans to address mental health needs.
Enhanced Continuing-Care: Community Recovery and Resource Center: The WCC Project proposes
to establish a pilot Community Recovery and Resource Center (CRRC) in East County. The CRRC is
designed to provide women in intensive day treatment, a drug-free environment in the community during
the late afternoon, evening, and weekend hours; and provide women in later recovery, continuing access
to a drug-free supportive and fun environment. The ultimate goal of the CRRC is to build a supportive
community among women substance abusers in recovery and their families. The Center will be housed
at Centurion Plaza, an East County location which currently hosts a number of critical service providers
MaryForan, California
Chuck Deutschman, California
including Occupational Rehabilitation Services, Head Start, Options for Recovery's Case Management
services and Ujima East Intensive Day Treatment Center, PATHS, a homelessness prevention project,
as well as Case Management for pregnant and parenting teens. The Pittsburg Health Center is only
several blocks away. The site is easily accessible by public transportation.
Health Services Lease Management has contacted the owner and space is available. The property is a
competitive rental commercial space. We are currently renting property for Ujima East and OFR Case
Management at the Centurion Plaza. Because the property is in a commercial, rather than residential
area, no change of use is required. The City of Pittsburg is notified when Health Services leases space
for programs. Approval was granted routinely when Centurion Plaza space was leased for the above-
named programs. We do no anticipate any barriers to concluding a lease agreement for the Community
Recovery Resource Center.
The CRRC will offer essential health and human services on-site such as child care; children's recovery
groups; health education and testing for communicable diseases; Twelve Step groups (eg AA, NA, IA),
family violence services; parent support groups, vocational rehabilitation services; GED assistance;
financial and daily living skills training; housing assistance; services to support and enhance self-esteem,
and transportation coordination. (See Appendix VIII, Document 11 for proposed CRRC schedule)
The Health Services Department will subcontract administration of the CRRC out through a competitive
bid process. The chosen service provider will be responsible for establishing and operating the Center.
The CRC will be open seven days a week between the hours of 4-10 pm and will be staffed by a full-time
SiteNolunteer Coordinator, Childcare Coordinator, and a team of volunteers; all of whom have been in
recovery for at least two years or more and understand the challenges facing women in recovery. Priority
will be placed on recruiting volunteers reflecting the cultural communities comprising East County's
service population.
The SiteNolunteer Coordinator will be responsible for overseeing day to day operation of the CRRC,
ensuring that a comprehensive array of services will be offered through volunteers and service providers.
The Coordinator will recruit women to help lead support groups and organize self-initiated activities.
These activities will, in large part, be coordinated by program participants. This volunteer opportunity
will enable women in recovery to practice the Twelve Step Tradition of service; giving back what one
receives.
The Child Care Coordinator will provide developmentally appropriate child care services at the CRRC
and train volunteers to provide same to cover most of the CRRC hours. The safe and sober supportive
environment existent at the Center combined with developmentally appropriate childcare will enhance the
existing service delivery system and support women's efforts to maintain a drug-free lifestyle. The Child
Care Council will assist the Child Care Coordinator with the volunteer recruitment and training.
Linkages. The WCC Project requires that close and cooperative working relationships exist among the
key project collaborators: Born Free, Tri-County Women's Recovery Services (Ujima East and West),
Living Free, Pittsburg Pre-School Coordinating Council, Contra Costa County Child Care Council, the
Children's Bureau of the Social Service Department, and within the Health Services Department, the
Community Substance Abuse Services Division, Office of Service Integration (which includes
Comprehensive Perinatal Services Program, Options for Recovery, Comprehensive Perinatal Outreach,
and Prenatal Care Guidance Program), Mental Health Division, Public Health and Hospital and Clinics.
There must be effective collaboration and coordination at both the management level and the service
delivery level if the project is to succeed.
The process of developing the WCC Project service system described in this proposal demonstrates the
collaborative alliances already in place in Contra Costa County. The Alcohol and Drug Abuse Perinatal
Mary Foran, California
Chuck Deutschman, California
Task Force (ADAPT) in existence since 1987, devoted two meetings to reviewing and providing input
to the WCC program plan. Decision-makers from all participating programs met several times to design
the program and work out the specific proposed characteristics.
All participating programs participate regularly in the policy and program development activities of
ADAPT and all, except Living Free and the Pittsburg Pre-School Coordinating Council, currently meet
monthly as the Options for Recovery Steering Committee to address the details of that program's ongoing
implementation and evaluation. (See Appendix II, Document 5 for the letters of commitment from
all agencies to participate in and carry out the WCC Project.)
Cultural Legitimacy. Contra Costa County has long been committed to creating a service delivery
system which is responsive to the needs of all of its residents. This commitment has been expressed
through the utilization of a model checklist for the. examination of cultural competence in social service
agencies developed by Dana, Behn and Gonwa; development of county-wide cultural awareness trainings;
priority on hiring staff from diverse cultural communities; and incorporation of cultural traditions and
sensibilities into service provision.
Cultural Competence Checklist. Contra Costa County substance abuse treatment providers serving
women and their children employ a checklist, developed by Dana, Behn, and Gonwa, to help assess and
evaluate cultural competency within their programs. This checklist reviews the practices, services,
culture-specific services, relationship to community, training, and evaluation practices used by each
provider. (See Appendix VIII, Document 10) This assessment mandates that each agency evaluate their
services from the perspective of a diverse service: population and respond to shortcomings within their
programs. It is recognized that cultural competence includes an ability to provide services that are
perceived as legitimate for problems experienced by culturally diverse persons.
Trainings. The Contra Costa County Training Institute, a county training resource, provides cultural
diversity training for all county employees on a regular basis. The Community Substance Abuse
Services, (the Health Services Department's Substance Abuse Division), provides periodic day long
trainings on cultural diversity to all substance abuse providers and also provides trainings specific to
women in recovery, focusing on the culture of women. The Born Free and Options for Recovery
Programs have held dialogues on cultural competency, inviting all staff members and friends to attend
and contribute to an ongoing discussion regarding cultural competence. In addition, Options for Recovery
is planning to hold a series of trainings that will enable OFR staff to more effectively serve the diverse
and specific populations seeking treatment.-The East Bay Perinatal Council developed a training on Afro-
centricity, creating a greater appreciation and understanding of the African American culture and
traditions and its impact upon service and individual recovery. ADAPT hosts dialogues on cultural
competency among perinatal substance services. The Office of Service Integration, the WCC Project's
lead agency, has focused on cultural competency as the topic of various staff meetings. And the Heritage
Project, Contra Costa County's specialized foster care services has developed a culturally competent
curriculum to train the foster care parents and relatives.
Staff Diversity. Contra Costa County substance abuse treatment providers serving women and their
children employ a staff which is representative of the population that it serves. A majority of the staff
are women who have been iq recovery, and who reflect the cultural diversity of Contra Costa County's
population.
Cultural Traditions. In addition to hiring staff representative of the cultures served and training all staff
on understanding and appreciating cultural differences, Contra Costa County providers are developing
greater awareness of cultural differences and providing women-centered treatment with appropriate
respect. For example, providers have developed an understanding of pregnancy rituals and family raising
customs. The programs have begun to incorporate the use of ceremonies, rituals, and special events from
Mary Foran, California
Chuck Deutschman, California
different cultures into their programs. Examples of this include culture-specific support groups, which
creates greater safety for group members, eg African-American Support Groups; incorporation of family
members into the program to help create and recognize extended family support in the lives of women;
and celebration of cultural traditions, eg. Cinco De Mayo, Kwanzaa.
E. EVALUATION PLAN
The Center for Applied Local Research (C.A.L. Research) will conduct the local evaluation for this
project. C.A.L. Research is a non-profit research organization dedicated to improving the quality of
human service delivery systems at the local level. C.A.L. Research staff members have extensive
experience in evaluating substance abuse and other human service projects throughout the State of
Califomia. C.A.L. Research's letter of commitment, organizational evaluation qualifications and
evaluator resumes are included in Appendix VIII/Document 5 and evaluator biographical sketches are
included in Appendix V/Document 7.
The evaluation will contain both process and outcome related elements. C.A.L. Research will consult
with project staff intensively during the start-up period to ensure that all protocols and procedures are in
place and to make any adjustments necessary to existing data collection efforts for the Women's
Continuum of Care Project. Evaluation staff will also consult with project staff on a regular basis
throughout the life of the project to ensure that the evaluation design continues to "fit" the program design
as the program changes and develops over time.
Evaluation activities will.be enhanced by the extensive, automated, Management Information System
maintained by the Office for Service Integration of the County's Health Services Department. The system
contains a large amount of descriptive demographic data on women (and children) receiving substance
abuse services in Contra Costa County, as well as data on numerous outcome measures detailed below.
This system has been in development for the past two years and data have just recently begun to be
entered. Five of the six sites in the WCC Project currently provide data for this automated system.
During start-up activities, the Evaluation Director and the Project Director will work with the one site.
(that is involved in a CSAP evaluation) to ensure that all six sites will be providing comparable data.
All existing data collection instruments are included in Appendix VII.
Process Evaluation. The process evaluation will serve several important goals: 1) It will assess the
extent to which the program is accomplishing its objectives and identify any impediments to
implementation; 2) It will play a "formative" role in helping to shape the program; 3) It will provide
clients with a "safe" opportunity to give feedback to the program; and 4) It will document the essential
aspects of the program in order to facilitate future replication. The process evaluation will include several
components:
Compilation and Analysis of Client Characteristics: All treatment sites utilize the standardized
treatment admission form that is part of the California Alcohol and Drug Data System (CADDS) as well
as extensive supplemental intake and assessment forms to capture additional information that is
particularly important to programs working with women who have children. Information is recorded
regarding age, referral source, nature and extent of substance use, number.of prior treatment episodes,
legal history, health status, pregnancy status, children's health, family and community support systems,
education and employment history, and date and reason for discharge. These data will allow evaluators
to describe the characteristics of the populations being served, as well as link these demographic
characteristics with outcome measures described below.
Analysis of Program Attendance/Service Utilization Through the Office for Service Integration's Client
Tracking System, evaluators will assess participants' attendance and service utilization. These data can
serve as independent variables in an outcome analysis (i.e. does attendance affect treatment outcomes?),
11
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or as dependent variables (i.e. Do certain demographic characteristics affect program attendance or
service utilization?).
Client Focus Groups Evaluation staff will conduct two focus groups per year--each with 10-12
participants—at each of the six sites. Group discussions will concentrate on clients' satisfaction with
various program components, unmet needs, barriers to obtaining needed services, with special emphasis
on the Resource Center being piloted in East County.
Staff Interviews Evaluators will interview WCC staff members and staff from the six outpatient
treatment sites and the Pittsburg Pre-School Coordinating Council once per year. These interviews will
include questions regarding the program's philosophy and structure, and relative success of each program
component and coordination in the service delivery system.
Quarterly Staff Conferences Evaluators will meet with WCC staff and staff from the six outpatient
treatment sites and the Pittsburg Pre-School Coordinating Council on a quarterly basis to provide
feedback to staff based on evaluation activities.
Observation of Program Activities Members of the evaluation team will periodically observe and take
structured notes on WCC funded services and activities.
Outcome Evaluation. The Contra Costa County Health Services Department and C.A.L. Research look
forward to and specifically agree to participate in and assist CSAT's national evaluation. The local
outcome evaluation will include three principle components: 1) An analysis of treatment outcomes; 2) An
analysis of changes in our clients' life circumstances; and 3) An analysis of changes in the developmental
and health status of clients' children.
The analysis of substance abuse treatment outcomes will focus specifically on: 1) Clients' successful
completion of the treatment process; and 2) Changes in clients' self-report use and abuse of alcohol and
other drugs. Data for the successful completion of treatment study will consist of CADDS admission and
discharge data, toxicology screens for pregnant women who give birth while receiving WCC Project, and
data from the various other assessments administered at regular intervals by the outpatient treatment
programs participating in the WCC project. The: analysis will consist of two phases: 1) Univariate
analysis (using t-tests), comparing the demographic characteristics for those who complete treatment with
those who do not complete; and 2) Multivariate analysis (using discriminant analysis) to develop a
predictive model of treatment completion.
The analysis of changes in clients' self-reported use and abuse of substances will compare clients' self
reports regarding use at three different time intervals: 1) During the month prior to treatment admission;
2) During the month prior to a follow-up interview that is scheduled for approximately six months after
discharge from treatment; and 3) During the mondi prior to exit from case management (which can be
up to two years in duration).
Data for type and frequency of use (ranging from no use to daily use) will be collected from CADDS
treatment admission, discharge, follow-up supplemental forms; outpatient program intake and assessment
form; and the Case Management Intake, Pregnancy outcome, Follow-up and Exit Form. Data will be
collected for a wide variety of drugs including alcohol and tobacco. Non-parametric, rank-order tests
will be used for all pre-post comparisotis.
The analysis of changes in clients' life circumstances will cover a wide range of outcomes, including
health and mental status, pregnancy status, family and community support systems, legal status,
employment status and utilization of public services. Analysis of most of these "circumstances" will be
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conducted for the same intervals forms listed above are completed. Analysis of public services utilization
will be assessed at outpatient treatment intake and thereafter in regular six month intervals.
Finally, in order to assess developmental changes in the children's lives, children of women enrolled
in the outpatient treatment programs participating in the WCC project are assessed by the Denver
Developmental Screening Test II. In addition, children with delays will be followed by the child
development specialist and/or enrolled in appropriate developmental services. Case management follow-
up forms will contain a variety of child health indicator data and will collect reports of all developmental
services provided.
Analytic methods for the above measures of changes in life circumstances, including child development,
will vary depending upon the particular item, and will include: t-tests, non-parametric comparisons of
rank order, and analyses of covariance.
Evaluator Staff Oualifications and Proposed Staff: See Appendix VIII/Document 7.
F. PROJECT MANAGEMENT, ORGANIZATIONAL STRUCTURE, AND
IMPLEMENTATION PLAN
Provider Background. The Contra Costa County Health Services Department is serving as the lead
applicant for the Women's Continuum of Care Project. This Department has extensive experience in
providing intervention and treatment services. Existing services include detoxification programs,
residential-recovery and treatment programs, outpatient counseling services, intensive day treatment case
management services, prenatal jail services, prenatal and HIV/AIDS street outreach, and perinatal
substance dependency intervention.
Many of these services are subcontracted out to community-based service providers, working in
collaboration another to address increasing community needs. This practice is based on a philosophy of
community recovery and cultural sensitivity.
Description of Substance Abuse Treatment Programs Serving Women and Children. The Born Free
Project is a model demonstration project, jointly funded by the Center for Substance Abuse Prevention
(CSAP) and the Contra Costa County Health Services Department Substance Abuse Division which
promotes family recovery from the addictions to.alcohol and other drugs. Born Free counselors conduct
interventions with women substance abusers at the three largest prenatal clinics in the County as well as
in the labor and delivery unit at the County hospital. In addition, the project provides services to women
in the Martinez detention facility, a component funded by Perinatal Treatment Expansion Project funds.
The Program serves a total of 72 women at any given time in outpatient treatment and another 25 women
in the detention facility. The Born Free Project outpatient services are MediCal ready and certification
is pending.
The Infant Bond Project, operated by the non-profit Early Childhood Mental Health Program, is a home-
based early intervention mental health program for families with infants and toddlers. The program offers
home-based assessments, weekly drug treatment groups, weekly in-home infant psychotherapy, infant
testing assessment, prevocational workshops with accompanying child care, men's counseling groups,and
help attending Alcoholics Anonymous or Narcotics Anonymous meetings. The program serves a total of
24 families at a time. (This program remains part of the network.of services, but will not participate in
the WCC Project except as a referral services, because of its existing emphasis on mental health and child
development services.)
The Living Free Project, a perinatal substance abuse project funded by CSAP and operated by Contra
Costa County Social Service Department, is an intensive, comprehensive, family-centered day treatment
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program which utilizes a multi-disciplinary team approach to enhance parenting skills, build the
mother/infant bond, and treat chemical dependency. (The Living Free Project is not currently certified
by California Drug and Alcohol Programs nor is Medi-Cal certification in the works. Client participation
is mandatory by Child Protective Services (CPS) and the Juvenile Courts. The Demonstration Project
works jointly with several agencies in an interagency collaboration and is mandated to serve annually
between twenty (20) to thirty (30) mother/infant pairs. The daily curriculum is a highly structured
program which includes three separate and distinct components: Bonding and Attachment; Substance
Abuse Recovery Counseling; and Parenting Education and Life Skills Training and Management.
Options for Recovery, operated by the Health Services Department Office for Service Integration, is a
state-funded model demonstration project which provides case management, treatment, and specialized
foster care services to addicted pregnant women and women with young children. The project
collaborates efforts between the Born Free Project, (offering case management services to 75 women and
their children);East Bay Perinatal Council, (offering case management services to 100 women and their
children); Tri-County Women's Recovery Services, (providing residential and intensive day treatment to
75 women and their children. The intensive day treatment services are licensed by California Drug and
alcohol Programs and Medi-Cal certification is planned); the Heritage Project, (providing training and
respite services to newly recruited foster parents from communities served); and the County Departments
of Social Service and Health Services.
The Perinatal Treatment Expansion Projects (PTEP), funded by the California Department of Alcohol
and Drug Programs (ADP) and administered by Contra Costa Health Services Community Substance
Abuse Division, are provided by contract through Tri-County Women's Recovery Services, (offering
transitional housing for 12 women and children);; the Born Free Jail Project, (providing assessment,
consultation counseling, referral, and advocacy for 25 women in jail); and East County Community
Detoxification Services, (providing transitional housing for 12 women and children.)
The Pittsburg Pre-School Coordinating Council;, a community-based, non-profit agency. Founded in
1972, provides quality day care to low-income families, education, training and temporary social services
assistance. PSCC uses trained staff to provide low- or no-cost year-round therapeutic licensed day care,
Monday-Friday from 8 a.m. to 4 p.m. for 15 infants and toddlers whose mothers have a substance abuse
problem and/or are homeless.
The Contra Costa County Child Care Council, a non-profit corporation, offers a variety of child care
services through its three office locations including child care referral, subsidies, resources, a food
program, recruitment and training of quality providers, assessment of child care programs, and public
education and advocacy about child care needs and issues.
Organizational Structure. The Health Services Department's Office for Service Integration will carry
out implementation of Contra Costa's Women's Continuum of Care Project. The plan for management
reflects the collaborative and interagency character of the project. The management plan rests upon
several successful experiences in Contra Costa County of integrating programs across departments,
including Healthy Start, Born Free and Options for Recovery.
The OSI Director and the gommunity Substance. Abuse Services Director will serve as co-principal
investigators for the project, providing overall direction for its implementation. Both report to the Health
Services Director. The Director of the Office for Service Integration will supervise administratively all
staff hired, as well as oversee administration of the project contracts and the budget. Clinical staff—
Public Health Nurses, Psychiatric Clinical Nurse Specialist — will receive clinical supervision from the
Public Health Clinical Services Manager and the Medical Director in Mental Health, respectively.
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The Director of OSI has chaired ADAPT since its inception in 1987 and is currently Project Director for
Options for Recovery. As Director of the Office for Service Integration, which is part of the Health
Services Director's Office, she is responsible for creating structures and programs which bridge the
various Divisions of the Health Services Department.
The relationship between Office for Service Integration and the other major divisions of the Department
are shown on the organizational charts for the Women's Continuum of Care Project in Appendix
IV,Document 6. The women's substance abuse programs within the Office for Service Integration and
the Community Substance Abuse Services Division are linked through the monthly ADAPT meetings,
monthly OFR Steering Committee meetings and regular consultation among program coordinators
The collaborative implementation of the project will be carried out at four levels:
1. A large broad-based group, involving all agencies and individuals concerned about perinatal
substance abuse, will advise on broad project design and direction, discuss community service
gaps and needs and be a forum for identifying potential solutions to problems encountered,
especially in the area of needed and desired service linkages. This group is known in Contra
Costa County as ADAPT. ADAPT's monthly meetings will be the avenue for broad community
input to the project. (See Appendix IV, Document 6 for list of agencies participating in
ADAPT.)
2. ADAPT will advise the WCC Steering Committee. The role of the Steering Committee will be
to guide and support the Project Coordinator and to be a sounding board for problems and a
resource for solutions. The Steering Committee will give final approval on all policies and
procedures. The WCC Steering Committee will be chaired by the OSI Director and staffed by
the Project Coordinator. Members will include directors/managers of the participating programs
-Born Free, Tri-County Women's Recovery Services, Contra Costa Child Care Council, Living
Free, Pre-School Coordinating Council, the Community Substance Abuse Director, the Medical
Director of Mental Health (who is the consulting psychiatrist) and the Community Recovery
Center provider. The Steering Committee will meet monthly at first and then every two months
as the project matures. Meetings will be open but only designated members will approve
policies.
3. Ad Hoc Committees will be the key to successful interagency management of the project. These
committees, interagency and interdisciplinary, will be created as needed during the project in
order to do specific implementation problem solving. The Project Coordinator's role is to assure
that a cohesive whole merges from the process. The Co-Principal Investigators will mediate
conflicts and the OSI Director will make final decisions in the event that the consensus building
process breaks down.
4. Joint collaborative service team meetings and multi-disciplinary case conferences will occur in
each area of the county in order to promote coordinated service planning and delay.
This four-level model of interagency implementation has emerged from the Department's experiences of
initiating Born Free and Options for Recovery. It is tested. It is a flexible system for assuring
collaborative decision-making, while.establishing clear lines of authority and accountability. (Refer to
Appendix IV, Document 6 for Organizational Chart)
Organizational Capability. The Contra Costa County Health Services Department is responsible for
providing a wide range of health services to County residents, including medical and preventive services
to individuals as well as environmental and public health services that protect the well being of the entire
community. The County works cooperatively with federal, state, and regional health services agencies
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and with private sector and community-based providers to ensure that comprehensive health care is
available at the local level.
The Contra Costa County Health Services Department has a long history of developing and implementing
collaborative, interagency projects such as that proposed here. Examples include:
• The Options for Recovery Executive Committee which was established by the department to
provide linkage among treatment programs, foster care, and health providers; creating increased
communication and resource sharing.
• The Born Free Executive Team, reflecting the inter-divisional nature of the Program was
established to advise the Project Director.
• The establishment of the Alcohol, Drug Abuse and Pregnancy Task Force (ADAPT), the
Advisory Board for the Women's Continuum of Care Project, a coalition of more than thirty
County agencies, community-based organizations, and community members that focuses on
developing substance abuse services for women of childbearing age.
• The Interagency Council of Infant Services includes all public and private agencies serving
developmentally disabled infants and those at risk.
The Department has developed and implemented .a comprehensive, collaborative network of services for
women which simply did not exist seven years ago.
Project Management Plan. The WCC Project will incorporate the efforts of treatment providers, health
care providers, mental health specialists, child development specialists, and program evaluators. A
detailed program management chart describing individual tasks to be performed; the sequence in which
these tasks will be performed; a description of sequential relationships; the level of effort required per
task project activities, the person responsible and the date by which each task will be accomplished can
be found in the Appendix VIII, Document 10, as per permission from CSAT staff member, Donald
Streeter.
G. PROJECT STAFFING
The Project Staffing chart in Appendix VIII Document 10 displays the positions and contract services
which will be supported by the WCC Project budget. It does not show the in-kind positons of Co-
Principal Investigators and Psychiatrist. The Psychiatrist is currently the fill-time Medical Director of
the Mental Health Division. He will devote 10% time to supervising the dual diagnosis component of
the Project, as well as consultation to the Family Practice Physicians. The Co-Principal Investigators are
the Directors of the Community Substance Abuse Services (5%) and the Office for Service Integration
(OSI) (20%). Both are full-time employees.
The Health Services Department is committed to effective implementation of the WCC Project. The
Department assures CSAT that all staff assigned to the Project will be available at a mimimum for the
amount of time indicated. Additional time will be provided as required to meet Project objectives.
Procedures for Staff Recruitment, Selection and Training. Recruitment for currently unfilled positions
will begin as soon as notification of the award is received. The Health Services Personnel Department
maintains an extensive list of culturally-specific organizations and other community based and women-
centered recruitment resources and advertises in Bay Area and California papers. The WCC Project will
be assisted as well, by the members of ADAPT, the participating providers, and especially by the East
Bay Perinatal Council which has an excellent track record in recruiting and retaining African-American
staff. The relevant professional organization: will be contacted including any special minority
professional groups especially in the fields of child development and dual diagnosis.From previous
experience in recruiting to fill the Options for :Recovery administrative and direct service positions,
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personal contacts to find highly qualified multi-ethnic candidates is key. Administrators and staff in the
participating do reflect the diversity of the populations served.
The Department places a high priority on finding staff for this Project which will continue to building
the diversity of the program's personnel. Final candidates will be brought to the Project Steering
Committee for approval in order to assure all are comfortable with the final selection. This process was
used very successfully to hire the supervisory staff in Options for Recovery (6 positions).
Several vacant positions — Public Health Aides and Child care Workers — will be advertized widely in
writing and by word of mouth in the geographic areas to be served with the goal of finding recovering
people and those with a special interest in working with substance abusing women. Please see Appendix
V, Document 7 for the WCC Project Job Descriptions and biographical sketches.
H. BUDGET, BUDGET JUSTIFICATION AND EXISTING RESOURCES
Increased/Enhances Activities: The significant new resources to be made available by the WCC Project
budget for substance abusing women and their children include a Community Recovery Resource Center;
increased capacity for children at the treatment sites — they will receive developmentally appropriate
childcare;developmental assessments, monitoring and intervention for substance-exposed children;metnal
heatlh assessment and intervention for dual-diagnosis women participating in treatment; health and
nutrition education, screening and liaison to primary medical care; access to family practice-based
primary care with an addiction medicine expertise.
Costs per Patient: The estimated cost per patient for these new services is caluclated simply by dividing
the total annual costa of the program (500,000) by the total number to be served annually (294). The
result is $1700 per women participant per year. This includes benefits to her children and to families
which participate in the Community Recovery Resource Center. It also includes evaluation and project
administration expenses.
Line Item Budget and Justification:
Personnel FTE Annual Salary Coun Federal
In-Kind
All salaries quoted are set by the County Personnel Merit System
1. Co-Principal Investigators
M. Foran 20% $ 61,000 $ 12,200
C. Deutschman 5% 67,000 3,360
2. Project Coordinator 50% 50,000 $ 25,000
3. Public Heatlh Nurse 50% 64,000 32,000
4. Public Health Aides (2) 200% 23,000 46,000
5. Child Development Specialist 100% 35,000 35,000
6. Psychiatrist Clincial Nurse
Specialist 0 80% 61,700 49,360
7. Family Practice Physicians (3) - 12% 39.63/hour 9,909
Total Direct Personnel 197,269
Frin a 63,126
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The current fringe benefit rate for County employees is 32%. It includes FICA, sick, vacation and
holiday time, employer share of medical and dental insurance, retirement contribution and workers
compensation.
Travel $7,248
Mileage for all employees is calculated at $.28 per mile for an average of 300 miles per month. Some
staff will do less travel, but the Psychiatric Nurse and Child Development Specialist will be traveling the
length of the County (50 miles) frequently in order to visit all participating sites on a regular basis.
This category also includes funds for the Project Coordinator to attend one three-day national technical
assistance meeting per year ($1200).
Equipment 6,000
Anticipated equipment needs are limited to adding terminals, printers and modems to link three more sites
(Living Free, Born Free, in East and West County), into the existing automated data collection system.
Office Supplies and Operations 7,650
This category includes general office supplies, postage and duplication for directly supported staff(4.6
FTE) estimated at$50 per month ($2750). Telephone installation and ongoing charges for new hires (4)
at $50 per month ($2400). Includes allowance for office furniture for the new hires ($2500).
Other 4,127
This category is to purchase child-related supplies for the participating programs including toys, blankets,
cribs, developmental play and educational materials.
Total County Personnel and Direct Costs $285,420
Contractural
1. Tri County Women's Recovery Services 50,000
The current contract with Tri-County, Ujima East and West, will be amended to add funds to support
two additional child care workers, each estimated at $20,000 annual salary and 259 for benefits.
2. Child Care Council 19,200
150 hours of consultation and training time by the Assistant Director at $50 per hour ($7500). Bom
Free's additional childcare capacity will be achieved through contracting with the Child Care Council to
hire 15 hours of child care staff per week. Rate; is $15 per hour which includes Child Care Council
Administration. Total child cost is $11,700.
3. University of California Cooperative Extension 5,600
Twice a year class series on nutrition will be provided at the 7 participating sites at a cost of$400 per
series. This covers staff teaching and preparation time, travel and handouts for participants.
4. Community Recovety Resource Center $89,769
Personnel
1. Site/Volunteer Coordinator $35,000 annual salary 26,250
allowing for start-up, will work nine months the first year.
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2. Child Care Coordinator $25,000 annual salary $18,750
Also assumed at 9 months per year for year one
Total Personnel 45,000
Frin e - Estimated at 21% for community non-profit agency 9,450
Travel - $.28 per mile for 150 miles per month for 9 months 504
Equipment and Furniture - Office furnishings, small copier, couches, chairs, tables 3,000
lamps. Expect much will be donated.
Office Supplies and Operations - Phone installation ($150) and monthly charges ($50) 2,315
Office supplies at $35 per month. Purchase of educational materials, posters for space ($600).
Training and participation in conferences ($800).
ace - 2000 square feet at$1.25 per square foot for 9 months ($22,500). Utilities at 32,200
at $50 per month for 9 months ($450). Janitorial at $25 per month for 9 months ($450) 2,250
Minor alterations and renovation of leased space to provide separate areas for childcare and office
coordination activities. Estimated at $7,000 in year one which is based on renovating similar space for
similar purposes.
In years two and three the CRRC budget will increase to cover 12 months of operations, but one time
cost will decrease.
5. Evaluation by CAL Research 50,011
1. Project Supervisor 48 hrs $ 33.36/hr 1,601
2. Project Director 370 hrs $ 27.16/hr 10,049
3. Sr. Research Associate 184 hrs $ 23.24/hr 4,276
4. Research Assistant 170 hrs $ 13.00/hr 2,210
5. Projected salary increases (promotions, annual merit and COLA, March, 1994) 2,176
Total Direct Personnel 20,312
Fringe 9,069
Includes FICA (employer's share), State Unemployment Insurance, Workers' Compensation Insurance,
Leave (sick, vacation, holidays), Insurance (life, health, vision, and dental), Training allowance, and
Retirement Contributions.
Other Direct Costs
Mileage @ $.24 per for site visits, meetings and focus groups 346
Telephone @$15/month in local calls 180
Postage & Shipping @$12/month 144
Duplication and Reports 3844 pgs at .07/page 270
CSAT Conference Attendance (for Evaluation Director 1300
Airfare (500); Hotel (500); Per Diem (200); Ground transportation (100)
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Total Direct Costs $34,021
Indirect Costs (40%) (This includes rent, utilities, custodial, supplies, 13,609
local telephone, insurance, accounting, legal, depreciation, and management
salaries and expenses.
Fee (5%) C.A.L. Research charges a 5% fee to all county and city agencies., 2,381
This fee supports pro bono work and helps to cover cost over-runs.
in