In Kentucky, nearly 90% of children three years and younger in out-of-home care have risks to safety due to parental substance abuse, yet services are limited. To address this need, the Sobriety Treatment and Recovery teams (START) program and related collaborative practices have been implemented in Owensboro, serving Daviess County in northwestern Kentucky where currently only 50% of DCBS clients needing substance abuse treatment receive any services. START is an evidence informed practice with four publications in peer-reviewed journals and a listing on the California Evidence -Based Clearinghouse for Child Welfare. START pairs specially trained CPS workers with Family Mentors (peer support specialists in recovery), comprehensive behavioral health treatment, parenting supports and community wrap-around to deliver an evidence-based intervention guided by the Model of Change and implemented with a system-of-care approach. START is designed to keep children safe in permanent homes and nurture their wellbeing; to promote sobriety, recovery and parental capacity among substance-abusing parents; and to build community capacity for recovery supports to address co-occurrence of child maltreatment and substance abuse. Funds are used to hire family mentors, provide high quality behavioral health treatment services, conduct a rigorous local evaluation, participate in the cross-site evaluation, administer the grant and support dissemination and collaboration efforts. New opportunities for sustainability exist, including expanded Medicaid funding and the Kentucky Title IV-E Waiver demonstration project involving START. Program evaluation includes measures of fidelity and formative evaluation that are used for program improvement using an empowerment evaluation model. These formative processes complement a mature program evaluation with summative evaluation and the testing of the impact of strategies on outcomes to develop models of what works best for whom.
General: START in Daviess County will serve families meeting these selection criteria:
Families with new cases of substantiated abuse and neglect;
- AND substance abuse as a risk factor;
- AND at least one child five years of age or young;
- That do NOT have an open CPS case;
- AND are referred from the CPS intake team within 30 days of the CPS report.
In-home/Out-of-home Focus: The project serves children who reside both in home and out-of-home care, focusing on keeping children in the home when safe and possible.
Major Project Goals
Goal 1: The START Program is designed to keep children safe in permanent homes and promote their wellbeing; to promote sobriety, recovery and parental capacity among substance-abusing parents; and to build community capacity for recovery supports to address co- occurrence of child maltreatment and substance abuse.
Goal 2: Proximal outcomes of child safety and well- being, parent capacity to care for children, and improved systems collaboration are achieved using tested program strategies. Distal outcomes include preventing recurrence of child abuse and neglect, safely reducing placements in out-of home care, and improving long-term rates of sobriety.
Key Major Program Services
Case Management and Case Conferencing
Wraparound and In-Home Services
Mental Health and Trauma Services for Adults
- Trauma-Informed and Trauma Specific Services
Substance Abuse Treatment for Adults
Specialized Outreach, Engagement and Retention
- Family Mentors
- Specialized START worker
- Drug Testing
Aftercare/Continuing Care/Recovery Community Support Services
- Developmental Screening
- Developmental Services – First Steps, HANDS
- Trauma Services for Children/Youth
Cross-Systems/Interagency Collaboration – Clinical-Related Activities
- Cross-Training and Staff Development
Cross-Systems/Interagency Collaboration – Program and Policy-Related Activities
- Seeking Safety
- Helping Men Recover
- Living in Balance
- Cognitive Behavioral Therapy
- Motivational Interviewing
- Dialectical Behavior Therapy
- Medication Assisted Treatment for Opioid Dependence
Partner Agencies and Organizations
The Regional Partnership Grants encouraged service providers to develop and/or strengthen cross-system linkages between substance abuse treatment, child welfare, dependency court, and other service systems. The following partners are included:
- KY Department for Community Based Services (DCBS)
- DCBS - Two Rivers Service Region
- Administrative Office of the Courts
- Daviess County Model Court
Substance Abuse and Mental Health
- Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID)
- Substance Abuse Treatment Branch
- Child Services Branch
- River VAlley Behavioral Healthcare
- Daviess County Area Substance Abuse Policy (ASAP)
Institutions of Higher Learning
- Eastern Kentucky University
- University of Louisville
START is listed on the California Evidence Based Clearinghouse as a program with promising scientific evidence. Four peer-reviewed journal articles about START have been accepted for publication, and future publications focuses on outcomes for families who received medication-assisted treatment, the impact of family mentors and separate papers on the impact of START on fathers, mothers, children and families. The team anticipates submitting two manuscripts annually, as well as conduct presentations and other national venues to disseminate lessons learned and practice implications of START. A manual is under development that helps with replication and dissemination of the model.
Sustainability Strategies and Activities
Involvement of Partners: Partners engage in regularly scheduled committee meetings at both leadership and direct services levels. Each quarter, the START team meets with policy and program managers in the State's central office to revise policies identify practices that incorporate the learning from START.
Sustainability Approach: A blend of funding streams supports START, including Temporary Assistance for Needy Families funds. Kentucky expanded Medicaid under the Affordable Care Act and now includes substance use disorder treatment as a Medicaid service. This change has increased funding for substance abuse treatment by $17 million and includes peer support services. In addition, DCBS has entered into an agreement with the federal government to use Title IV-E funding through a waiver to expand START to an additional site and increase the number of families served in two existing sites.
Integrating Activities: A program evaluation report compared the quality of casework for START versus non- START teams in the same county. The evaluation found that START workers more thoroughly assessed each child's attachment and permanency needs, engaged community partners and families more often in decisions and provided higher quality of services to fathers with more visits, services and engagement in decision making. These START outcomes demonstrate that the START approach that emphasizes engagement yields better outcomes than business as usual, and can easily be applied in case practice.
Institutionalizing Strategies: Current evaluation data suggests that fewer children have entered state custody; the cost avoidance shows that for every $1 spent on START, more than $2 is avoided in out-of-home-care (OOHC) costs. Program evaluation that is rigorous, credible and focused on important results including cost avoidance is the best venue for sustaining a program or garnering additional funding.
In addition to serving families with children in, or at risk of, out-of-home placement and parental substance abuse issues, one aim of the RPG program is to broaden the child welfare and substance abuse treatment fields’ understanding of promising approaches to working with this population. To help build this knowledge, the Children’s Bureau requires each RPG grantee to conduct a local evaluation of its program. The Department for Community Based Services (DCBS) is evaluating the impact of its Sobriety Treatment and Recovery Teams (START) program using a quasi-experimental design. Families in the program group receive in-home support provided by a specially trained CPS worker and a family mentor and have access to wraparound services, while families in the matched comparison group receives usual child welfare services. The local evaluator also conducts focus groups with clients and partner staff.
Outcome Study Design: After families are identified as eligible for the START program, they are offered program services if space is available. All START families are invited to participate in the evaluation. Once families express interest in study participation, staff obtains written consent and conducts baseline and 12-month follow-up interviews.
For START families enrolled in the evaluation, DCBS is collecting primary and administrative data to assess outcomes related to child safety, permanency and well-being, adult recovery and family functioning and stability outcomes. The local evaluator has access to several administrative record databases: Kentucky’s Statewide Automated Child Welfare Information System (SACWIS), the Kentucky Treatment Outcome Study (KTOS), and the Treatment Episode Data Set (TEDS). Records of services provided to families in the program are maintained in a case management system called START Information Network (START-IN).
In addition to primary data collection with START families, the evaluation also uses propensity score matching to draw a comparison group from Kentucky’s SACWIS system. Criteria for matching is based on geographic area, demographics and a variety of adult and child risk and protective factors. This allows the evaluation team to compare outcomes for START families to those who receive usual services on the following outcomes: (1) children entering and exiting state custody; (2) recurrence of child maltreatment; and (3) reentry into foster care.
Additional Evaluation Components: The evaluator conducts focus groups with members of the following constituencies: START clients, CPS staff and community partners.
RPG National Cross-Site Evaluation Participation: DCBS provides data for the RPG national cross-site evaluation on the outcomes of its participants, contribute to a study of the implementation of RPG programs and provide information on its collaboration efforts for the partnership study. The grantee is also participating in a cross-site sub-study designed to examine the impacts on children and families of the national RPG program.
DCBS, as the lead child welfare agency, facilitates a regional partnership formed by collaborative agreements with the partners for the START Daviess county project. The members of the regional partnerships are all university or governing agencies with many years of experience in administering programs to serve the target population and evaluate program outcomes. DCBS contracts directly with the Community Mental Health Centers to provide substance use and mental health disorder treatment for START adults and children. Eastern Kentucky University hires all family mentors and provides fiscal administration. Oversight, management and leadership of the START program and grant activities is accomplished through a series of regular scheduled committee meetings at both leadership and direct services levels with all partners.