It is axiomatic that an attempt to address adolescent substance abuse problems will be less effective if youth and families fail to stick with the intervention long enough. One of the principal goals of the Reclaiming Futures Model is to implement performance management practices that allow communities to connect youth with appropriate resources and to monitor their interactions through to completion. Community coordination teams should specify how much of each service plan must be completed in order for the plan as a whole to be considered complete.

Another key concept in the Reclaiming Futures Model is that an intervention plan for justice-involved youth should be guided by, and rely as much as possible on community resources. Thus, completion of the service plan should be preceded by the gradual withdrawal of agency-based services and the engagement of youth and families in community resources and "natural helping" relationships.

"A 'successful' treatment episode can be characterized by three distinct phases, each of which presents opportunities for either success or failure. First, a client must contact the treatment system and access services (treatment access). Second, after contact has been made and a recommendation for treatment received, the client must begin attending treatment sessions (treatment initiation). Third, the client must stay in treatment long enough to complete the program, including aftercare (treatment completion). Factors that interfere with any of these phases are likely to lead to worse outcomes; for this reason, treatment process is of critical interest to practitioners" (Green et al., 2002: 285).

Green, Carla A. et al. (2002). "Gender differences in predictors of initiation, retention, and completion in an HMO-based substance abuse treatment program." Journal of Substance Abuse Treatment, 23(4): 285-295
McKellar, John, John Kelly, Alex Harris, and Rudolf Moos (2006). "Pretreatment and during treatment risk factors for dropout among patients with substance use disorders." Addictive Behaviors, 31(3): 450-460.

Of all youth engaged in services, how many (as a percentage) complete the service plan as designed?

Community treatment systems should track individual outcomes for all youth who are engaged in services, whether or not they actually complete the entire service plan.
Of all youth engaged in services who fail to complete the service plan, how many (as a percentage) are successful for at least one year?
Of all youth who complete the service plan, how many (as a percentage) succeed for at least one year? *

* Note: Success may be defined in various ways, including the absence of new arrests or new court referrals, no new drug use, reduced drug use, no subsequent referrals for drug or alcohol treatment, or some combination of these measures.

Youth and families must be effectively engaged in services. Engagement is defined as three successful service contacts within 30 days of a youth's full assessment. Engagement can be measured for each service component or for all elements of the service plan taken as a whole. Engagement should be monitored whether or not the intervention plan includes formal AOD treatment.

LESSONS LEARNED

"Treatment engagement is defined as an intermediate step between initially accessing care (in the first visit) and completing a full course of treatment. Numerous studies have indicated that individuals who remain in treatment for a longer duration of time have improved outcomes...the 1990 Drug Service Research Survey has suggested that many clients (52%) with AOD disorders leave treatment prematurely...studies have tied the frequency and intensity of engagement as important in treatment outcomes and reducing drug-related illnesses." (From the National Quality Measures Clearninghouse).

Hubbard, Robert L., S. Gail Craddock, Patrick M. Flynn, Jill Anderson and Rose M. Etheridge (1997). "Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS)." Psychology of Addictive Behaviors, 11(4): 261-278.
George W. Joe, D. Dwayne Simpson, and Kirk M. Broome (1999). "Retention and patient engagement models for different treatment modalities in DATOS." Drug and Alcohol Dependence, 57(2): 113-125.
National Committee for Quality Assurance (NCQA). HEDIS 2006. Health plan employer data & information set. Vol. 2, Technical specifications. Washington (DC): National Committee for Quality Assurance (NCQA); 2005. 350 p.

Of all youth who initiate a service plan, how many (as a percentage) become fully engaged in services?

Community treatment systems should track individual outcomes for all youth who initiate services, whether or not they become engaged with those services.
Of all youth who initiate a service plan but fail to become fully engaged, how many (as a percentage) are successful for at least one year? *

* Note: Success may be defined in various ways, including the absence of new arrests or new court referrals, no new drug use, reduced drug use, no subsequent referrals for drug or alcohol treatment, or some combination of these measures.

The first contact with a service provider (or "initiation") is a critical moment in any intervention plan. Consistent with the treatment standards of the Washington Circle Group initiation in the Reclaiming Futures model is defined as at least one service contact within 14 days of a youth's initial AOD assessment. Initiation can be measured for the entire intervention plan or for each component of the plan. Service initiation should be monitored whether or not the intervention plan includes formal AOD treatment.

The communities that served as demonstration sites for the Reclaiming Futures initiative learned important and sometimes painful lessons about service initiation. Tracking actual performance across bureaucratic boundaries led to one particularly important revelation in Dayton, Ohio. Once they began to monitor the movement of youth out of the court process and into the treatment process, juvenile probation officials in Dayton discovered that under previous practices, more than half of the youth referred for substance abuse treatment never appeared at their assigned treatment provider, and that information never found its way back to the referring agency.

McCorry, Frank, Deborah W. Garnick, John Bartlett, Frances Cotter, Mady Chalk, for the Washington Circle Group (2000). "Developing Performance Measures for Alcohol and Other Drug Services in Managed Care Plans." The Joint Commission Journal on Quality Improvement, 26(11): 633-643.

Of all youth who agree to complete an appropriate service plan, how many (as a percentage) initiate the services as designed?

Community treatment systems should track individual outcomes for all youth who are referred for a service coordination plan, whether or not they initiate services.
Of all youth who agree to a service plan but fail to initiate services as designed, how many (as a percentage) are successful for at least one year?*

* Note: Success may be defined in various ways, including the absence of new arrests or new court referrals, no new drug use, reduced drug use, no subsequent referrals for drug or alcohol treatment, or some combination of these measures.

Intervention plans for youth substance abuse problems should be designed and coordinated as a "system of care" using community treatment teams that are family driven, span agency boundaries, and draw upon community-based resources. The intervention plan should include whatever mix of services is appropriate for each youth, perhaps including AOD treatment, educational and preventive services, involvement in pro-social activities, and the assistance of "natural helpers" already known to the youth and his or her family.

Youth identified as having AOD problems at the point of assessment should be referred for appropriate services and care coordination, whether the service plan involves only short-term prevention and early intervention programs or more intensive and lengthy outpatient services and residential treatment. Effective service coordination should involve the family directly, be culturally competent, and include a diversity of community resources, even if some resources have to be developed anew. Services should be individualized and designed to allow each youth to achieve a defined set of positive outcomes.

In cases where formalized outpatient substance treatment is warranted, the Reclaiming Futures Model was designed to be consistent with the Washington Circle standards for determining appropriate levels of AOD services. The Washington Circle standards assert that if outpatient substance abuse treatment is indicated, at least four to six clinical sessions conducted by a licensed provider over no less than four weeks would generally be considered effective, not including continuing care (or aftercare). At least one therapeutic (aftercare) contact should occur approximately 90 days after the onset of treatment. Research suggests that success is improved the longer someone stays engaged in treatment. While the Reclaiming Futures Model does not require it, the length of substance abuse treatment should ideally extend to the maximum appropriate for a given level of AOD problems (periods of up to a year including aftercare have been suggested for youth in outpatient services).

Pumariega, Andres J. and Nancy C. Winters (Eds.) (2003). The Handbook of Child and Adolescent Systems of Care. San Francisco: John Wiley & Sons, Inc.
Kraft, M. Katherine, Kristin Schubert, Anna Pond, and Marliyn Aguirre-Molina (2006). "Adolescent treatment services: The context of care." In Adolescent Substance Abuse - Research and Clinical Advances. Howard A. Liddle and Cynthia L. Rowe (Editors). New York: Cambridge University Press, p. 174.

Of all youth identified with AOD problems at assessment, how many (as a percentage) agree to complete an appropriate service plan?

Whenever an initial screening suggests that a youth may have possible substance abuse problems, that youth should be fully assessed using a reputable tool that measures the degree to which the youth is being negatively affected by his or her use of alcohol and other drugs (AOD). Comprehensive assessments should measure a wide range of individual and family risk factors, service needs, as well as the youth's strengths and assets. While the primary purpose of an initial assessment is to measure the severity of AOD problems, a second and equally important purpose of an assessment is to shape an informed service plan.

In some of the Reclaiming Futures demonstration sites, juvenile justice practitioners determined that the most effective reform would be to move the timing of assessment up to make the results available earlier. For example, the juvenile court and juvenile bar in Marquette, Michigan collaborated to make substance abuse assessment results available immediately upon the completion of delinquency adjudications so that each treatment plan could incorporate recent and accurate information about the extent of a youth's substance abuse problems.

Winters, Kenneth C. (2006). "Clinical perspectives on the assessment of adolescent drug abuse." In Adolescent Substance Abuse - Research and Clinical Advances, Howard A. Liddle and Cynthia L. Rowe (Editors). New York: Cambridge University Press, p. 223.
Allen, John P. and Veronica B. Wilson (Editors). 2003. Assessing Alcohol Problems: A Guide for Clinicians and Researchers (Second Edition). Washington, DC: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism [NIH Publication 03–3745].

Of all youth identified with potential AOD problems at screening, how many (as a percentage) go on to get a full assessment?

Jurisdictions should track individual outcomes for all youth identified with potential substance abuse issues at screening, whether or not they are later assessed.
Of all youth that do not get full assessments after being identified with AOD problems at screening, how many (as a percentage) are "successful" for at least one year?*

* Note: Success may be defined in various ways, including the absence of new arrests or new court referrals, no new drug use, reduced drug use, no subsequent referrals for drug or alcohol treatment, or some combination of these measures.