Therapeutic Intervention, Education, and Skills (TIES) addresses the complex needs of children (age 0-17) who are in or at-risk of out-of-home placement due to parent/caretaker substance abuse and establishes and implements an evidence-based, trauma-informed, culturally competent continuum of outreach, treatments, education/counseling and supportive services for children and families utilizing all components of high fidelity Intensive Family Preservation Services (IFPS) in conjunction with Seeking Safety, as appropriate, for participants with a history of trauma. The project bridges a significant gap in locally available family treatment services. In 2011, parent/caretaker substance abuse issues were a primary factor in more than half of all out-of-home placements in the target area. Of the children in Tennessee state custody, those coming from substance-affected families experienced more severe and chronic abuse and were more likely stay in, return to and have siblings in out-of-home placement. Studies show that children of substance-using parents often turn to substance use themselves to escape the emotional trauma of abuse and/or neglect. TIES integrates project staff into existing behavioral health teams in the target area, ensuring integrated services and enhancing continuity of care for participating families. Using high fidelity Intensive Family Preservation Services with Seeking Safety as appropriate, TIES supports and helps strengthen at-risk families by providing services that reduce the need for out-of-home placement and promote child safety, permanency and well-being. Through a collaborative effort of agencies and organizations, families are provided interventions that build skills and capacities contributing to healthy, well-functioning families. TIES provides in-home counseling, basic skills, and parenting education, psychosocial education and linkages with social/community services. Program staff links parents/caretakers with substance use treatment programs/recovery supports and ensures access to needed services. TIES therapists are available 24/7 to provide crisis intervention and intensive services to keep children out of harm's way. TIES establishes a Steering Committee with representation from all project partners as well as local service agencies, government agencies, funding stream representatives, individuals in recovery, parents/caretakers and other community stakeholders that work to ensure sustainability of the project. TIES conducts an ongoing comprehensive program evaluation that includes assessing the degree and nature of interagency collaboration in community partnerships and how they change over time.
Project performance measures will be developed and disseminated as a documented service model for replication across the state and nation. The performance measure areas will include:
- Documentation of fidelity
- Cost effectiveness
- Follow-up data
General: The target population for TIES is families with children who are in or at-risk for out-of-home placement as a result of parent/caretaker substance abuse.
Adult Inclusion/Exclusion Criteria: The project serves only families with children who are at-risk for out-of-home placement or who are in placement but identified as candidates for safe reunification via project enrollment.
Major Project Goals
Goal 1: Enhance and expand regional collaborative infrastructure/capacity to meet a broad range of needs for families involved with both substance use treatment and the child welfare system.
Goal 2: Establish and implement an evidence-based, trauma-informed, culturally competent, community-based continuum of outreach, treatments, education/counseling and supportive services for children and families utilizing all components of high fidelity Intensive Family Preservation Services (IFPS) in conjunction with Seeking Safety as appropriate for participants with a history of trauma.
Goal 3: Improve outcomes of children related to safety, permanency and well-being.
Goal 4: Increase family stability and improves participant outcomes related to substance abuse and trauma.
Goal 5: Develop and disseminate a thoroughly documented service model for replication across the state and nation.
Major Program Services
Cross-Systems/Interagency Collaboration – Clinical-Related Activities
Cross-Systems/Interagency Collaboration – Program and Policy-Related Activities
- Behavior Modification
- Motivational Interviewing (MI)
- Cognitive-Behavioral Therapy (CBT)
- Intensive Family Preservation Services (IFPS)
- Relapse prevention
- Skill building
- Linkage with natural supports
- Community engagement
- Family Therapy
- Families as experts on their family
Key Elements :
- Intervention at the crisis point within 24 hours of referral
- Treatment in family’s home
- Intensity – 8-10 hours of in-home services each week
- Research-based interventions
- Partnership with families
Mental Health and Trauma-Informed Services
Referral and linkage to Substance Abuse Treatment for Adults
Specialized Outreach, Engagement and Retention
- Priority access to treatment services
Referrals and Linkages to Children’s Services
- High fidelity IFPS program
- Seeking Safety
- Motivational Interviewing (MI)
- Cognitive-Behavioral Therapy (CBT)
Partner Agencies and Organizations
The Regional Partnership Grants encourages 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:
- Tennessee Department of Children’s Services (TDCS)
Substance Abuse and Mental Health
- Tennessee Department of Mental Health & Substance Abuse Services (TDMHSAS)
- Centerstone of Tennessee, Inc.
- Centerstone Research Institute (CRI)
With the guidance from the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS), TIES disseminates its findings at identified stages throughout the grant period. Dissemination efforts target professional, government, provider and lay audiences (e.g., legislators, media, educational institutions, courts, behavioral health organizations, participating families, etc.) via quarterly and/or annual activities such as presentations, website implementation, peer reviewed journals, newsletters, etc., as well as daily to monthly social media. The project develops and disseminates a thoroughly documented service model for replication across the state and nation. Internally, co-evaluation and program staff meetings feature ongoing reports on preliminary outcomes, as well as outcomes associated with fidelity monitoring specifically tailored to inform decision-making, improve program implementation and provide targeted information on progress toward goal achievement. Quarterly updates are provided to the TIES Advisory/Steering Committee on both process and outcome evaluation findings. Additional strategies include:
- A comprehensive evaluation with documentation of fidelity, process and outcomes; and
- A cost-benefit analysis to support policy recommendations for statewide implementation of model components that produce significant results
Products include a website, manuals, materials, publications and presentations for dissemination and replication of the IFPS/Seeking Safety service model. A dissemination toolkit with video clips and other visuals for promotion/adoption is developed for sharing statewide with providers/organizations serving similar populations across the state and nation.
Sustainability Strategies and Activities
Involvement of Partners: The grant’s Advisory/Steering Committee continues to explore creating a variety of sustainability subcommittees to identify/engage the committee and coordinate with potential sustainability sources in conjunction with the Principal Investigator/Project Director. All partners have representation on the Advisory/Steering Committee and have input into sustainability efforts. Additional stakeholders, including but not limited to, the Governor’s Children’s Cabinet, Bureau of TennCare, the Tennessee Department of Health, the Tennessee Department of Education, the Tennessee Department of Human Services and the Tennessee Administrative Office of the Courts have representation on the Advisory/Steering Committee. The Committee investigates other secure funding streams that include block grants, state funds, etc. The Committee is an advisory group for sustainability planning, providing oversight, direction and consultation to identify/seek funding through a variety of sources including; TennCare (Medicaid), private health insurance, Title IV-B & IV-E and other federal/state resources. The Committee considers policy/practice strategies as sustainability options.
Sustainability Approach: During the grant period, Therapeutic Intervention, Education, and Skills (TIES) focuses on integrating/delivering/sustaining quality family preservation and reunification services including linking the program to In-Home Tennessee, TDCS' current statewide initiative to expand/enhance evidence-based in-home service provisions for noncustodial families and IV-E Waiver strategies. Solidifying this infrastructure positions TIES to identify and seek funding through a variety of sources, including TennCare (Medicaid), private health insurance, Title IV-B & IV-E and other federal/state resources, resulting in a funding base built on the cost-effectiveness of project services. Sustainability efforts also include policy/practice changes across and/or among systems. The Committee obtains technical assistance from the National Center on Substance Abuse and Child Welfare regarding its sustainability direction.
Integrating Activities: The project integrates TIES staff into existing Centerstone behavioral health service teams to support sustainability and continuity of care. Moreover, TIES is represented through a number of activities across the state that focuses on child well-being, such as the Tennessee Young Child Wellness Council.
Institutionalizing Strategies: A legislatively mandated plan for statewide System of Care expansion continues to unfold, including comprehensive integration of children's services across providers. The evaluation plan incorporates comprehensive measurement of service cost and utilization outcomes, which in previous projects has proven useful as objective evidence for use in negotiation for sustainability funding. TennCare, the state’s Medicaid authority, re-visits its service reimbursement options that focus on children and families.
As a condition of receiving RPG funding, each grantee is conducting a local evaluation of its program. These evaluations help fulfill a key goal of RPG: to expand knowledge of approaches that improve the well-being and functioning of families in order to address the distinct risk of maltreatment among children from families affected by substance use. The evaluation of Therapeutic Intervention, Education, and Skills (TIES) use a comparison group design to study the outcomes of families who receive TIES relative to families who receive services as usual, but creation of a quasi-experimental matched comparison group for TIES research participants has been challenging. Matched variables from Tennessee’s Safety Decision Making (SDM) tool are used in creating the comparison group. The SDM had enough variability to match participants’ and non-participants’ level of risk. However, the Tennessee Department of Children’s Services, from whom the data would be obtained, is no longer using the SDM with families. At this time, the lead evaluator plans to use propensity score matching to establish the matched comparison group.
Outcome Study Design: Families with children who are either (1) at imminent risk of out-of-home placement – that is, removal within 48 hours or (2) currently in out-of-home placement and expected to reunite with their families within 72 hours may receive referrals to TIES from child protective services caseworkers. The comparison group is drawn from administrative child welfare data and comprises families with characteristics similar to those of families in the program group. Although the evaluation team is still finalizing match criteria, the following characteristics are being considered: number of times the family has been involved with the child welfare system, family composition, geographic area and variables from the Safety Assessment Tool and a 13-item checklist to assess the home environment and family relationships that Tennessee child welfare caseworkers use to triage families into services at different intensity levels.
The program evaluation team continues to track outcomes related to child well-being, permanency, and safety; adult recovery and trauma; and family functioning and stability. Primary data is collected on child well-being, adult recovery and family functioning from participants in TIES; secondary data from administrative records on child safety and permanency from national child welfare databases for both TIES’ participants and the comparison group is used during the evaluation. The Tennessee Department of Mental Health & Substance Abuse Services (TDMHSAS) has a data-sharing agreement in place with the child welfare office that manages administrative data for the state so data is made available to the Program Evaluation partner in order to identify comparison group families. Administrative outcomes of the comparison group and TIES’ families is examined.
Additional Evaluation Components: The evaluation team in conjunction with TIES program administrators and the Principle Investigator (PI) routinely track IFPS implementation using bi-annual chart reviews and the fidelity-monitoring instrument developed with the National Family Preservation Network (NFPN). Client charts are randomly selected for the review process. To monitor fidelity to Seeking Safety, therapists complete the Seeking Safety Module Checklist (developed by the evaluation team and introduced as part of the therapists’ charting requirements in January 2015). This checklist contains all 25 Seeking Safety modules and highlights the five required modules for the TIES’ program. Therapists check off the Seeking Safety modules completed during the case and fill in the date of completion. This checklist provides an initial way for program and research staff to confirm that therapists are completing 11 modules, including the five required modules, within the two-week Seeking Safety portion of the TIES program.
RPG National Cross-Site Evaluation Participation: TDMHSAS is participating in the cross-site evaluation of RPG, which studies family outcomes, program implementation and RPG partnerships across all 17 grantees. Moreover, TIES evaluators volunteered to involve the project in the piloting of evaluation tools for the national evaluation.
The roles and responsibilities of the Tennessee Department of Mental Health & Substance Abuse Services (TDMHSAS), under Therapeutic Intervention, Education, and Skills (TIES), include: (1) serving as lead agency, (2) providing oversight of the project and ensuring successful collaboration, service delivery, evaluation and sustainability activities are achieved and documented, (3) coordinating and participating in all TIES collaborative activities, (4) maintaining responsibility for the proper collection, storage, reporting and sharing of data, (5) maintaining ownership of data collected for the project and (6) providing semi-annual progress reports to the Administration for Children and Families and evaluation updates to all collaborating partners and appropriate stakeholders. To maximize the effectiveness of service delivery, partnerships are established between key state and local agencies, and partners facilitate and monitor implementation. A Memorandum of Understanding detailing partner roles, responsibilities and tasks is in place and extends through the life cycle of the grant. The Advisory/Steering Committee facilitates service coordination and integration across agencies when necessary. The Committee meets regularly to provide oversight, direction and consultation for TIES, especially around sustainability. In addition, the Advisory/Steering Committee ensures that outcomes delineated in the TIES logic model are met. The Committee remains apprised of ongoing/planned projects and activities that may need to be coordinated and integrated with TIES. Providing such information supports and helps ensure a seamless continuum of care for children and families. A Regional Collaborative Council continues to function and ensure service capacity for children and families in rural areas served by the grant.