Assessing the Context of Permanency and Reunification in the Foster Care System: Mothers Making a Change Program . 2.2 Staffing and Services


MMAC employs approximately 19 full- and part-time staff in both the Cobb County and Douglas facilities. MMAC staff interviewed seemed well educated with a considerable number of years of experience in their areas of work, although some had worked with MMAC for less than a year.(8) Staff working in the residential facilities and the program nurse are available 7 days per week, 24 hours per day if needed. Overall, staff seem very motivated, and dedicated to the success of clients. In addition to program staff, mothers who have completed the program come back and volunteer their time to assist with current clients. These women babysit children and attend sessions for clients and discuss their addiction and treatment.

Upon referral, MMAC's goal is to get women into the program for service within 12 to 24 hours. Once the client arrives, staff begin a lengthy orientation and comprehensive assessment performed by the program coordinator and other program staff. This assessment, done for every client, can take up to 2 hours and involves an evaluation that includes a complete physical and medical, psychosocial and substance abuse assessment using the Addiction Severity Index (female ASI) of psychosocial status. Nearly 100 percent of the women entering the program meet the American Society of Addiction Medicine patient placement criteria for treatment of substance abuse disorders. After the assessment process, a decision is made to determine the appropriate level of services needed -- either residential, day treatment, or outpatient services. The assessment team considers the level of treatment based on whether the client is an intensive addict who needs to work toward recognition of her problem and getting clean of drugs (recommended for residential treatment with no passes), a serious drug user who recognizes the problem and wants to cooperate with treatment (recommended for residential treatment with fewer restrictions), or an occasional drug user (generally recommended for the day treatment program). The assessment should be complete, and a meeting involving the client and family (if possible) takes place after 48 hours from the time of intake to the program. In the family meeting, the program coordinator, client, and family members discuss the client's placement in the program.

In addition to the general assessment, the coordinator of nursing services also provides a comprehensive health assessment and examination to all clients including a TB skin test, urinalysis for drug screening, and, with the client's consent, tests for syphilis, HIV, a Pap smear, and mammogram (these services are optional). Pregnant mothers are assessed for pre-natal care. If the drug screening is positive, and they determine that the client needs to be treated for detoxification, this takes priority over all other needs, especially if the woman is pregnant. The top priority at the program is that women deliver healthy and drug-free babies in order to deter CPS placement of the child once he or she is born. If detoxification is required, they quickly refer the client to the Detoxification Crisis Stabilization Center, where doctors, nurses, and psychiatrists provide 24-hour-a-day, 7-day-per-week services and support. Further referrals for neurologists or internists can be made if the client has special health problems such as seizures, depression, or diabetes. The nurse told us she places major emphasis on providing medical services that expedite reunification of families. She contributes to the assessment team that makes recommendations to DFCS and the court on the extent of recovery and health compliance of a client and whether reunification is possible.

Children entering the program with their parent also receive a health assessment to determine the status of immunizations and any special health needs. If any child lacks immunizations, he or she is referred to receive them. A client's child who is not residing in the program may be referred for health services to MMAC's Child and Adolescent Program. It is often the case that while the child may have health coverage, the mother may not due to unemployment, homelessness, or drug addiction. Therefore, MMAC assists the client in completing a form to qualify for Medicaid or other health coverage at the indigent clinic.

The nurse also is responsible for coordinating transportation services for clients to ensure that medical appointments are kept and visits the residential facilities at least once a week. She makes daily sick calls as needed Monday through Friday and is on call 24 hours a day, 7 days a week for emergencies. The nurse is also careful to note any medical needs in the discharge plans for a client.

Treatment and case plans are written by a multidisciplinary team based on their assessments of the client. The team includes the case manager, the client, the site supervisor, nurse, and other interested agencies. A client is informed about the shortened timetables under ASFA and that if she does not recover within that timeline, parental rights might be terminated. Concurrent planning is determined by DFCS, so it is possible that the foster care worker has a concurrent plan for the family. However, concurrent planning is not done at MMAC. While case management for the family remains with DFCS, DFCS often uses the MMAC case plan to assist in writing its plan due to the richness of information provided by MMAC. MMAC staff work closely with DFCS workers to create reasonable and realistic case planning for a family, although there may be differences of opinion on these points. If there are major differences between established DFCS and MMAC plans, MMAC and DFCS staff meet to discuss and resolve differences to establish realistic and attainable goals for a client. Case updates by MMAC to DFCS are done at the time of regularly scheduled case reviews. Otherwise, communication is open, and DFCS and MMAC staff may discuss a case at any time, on a case-by-case basis.

MMAC provides a variety of services through outpatient treatment, residential treatment, day treatment, health care services, and child care. The most common presenting problems of clients entering the MMAC are substance abuse, homelessness, lack of resources, and limited family support. The most commonly provided services are substance abuse treatment and housing. Since MMAC is considered a mental health program, it falls under the authority of a state HMO-type entity that dictates the length of time and type of treatment for state mental health and substance abuse patients. Although there was no indication by the director of women's services that this authority caused problems in serving clients, she did say that the state is in the process of changing the women's treatment program authorization protocol for substance abuse services, to give more flexibility for treatment in the MMAC program. Services are generally specified for a minimum of 6 months, and most clients receive services for 12-15 months, although the program may serve a client for up to 2 years.(9) MMAC believes that women who are able to stay longer in the program have more success in substance abuse treatment, which results in successful reunifications. High-risk families are served through a Family Preservation/Support Grant under the Adoption and Safe Families Act.

Residential Substance Abuse Treatment

The hallmark of the MMAC program is its residential substance abuse treatment services. The program runs two facilities, one each in Cobb and Douglas counties. The location in Douglas County is a seven-unit, gated apartment complex that was purchased through grant monies. The Cobb County facility consists of apartments rented by the program within an existing complex. Staff at both complexes are located on site 24 hour per day, 7 days per week to intervene, monitor, refer, and handle emergencies. There is also a doctor on call after hours for any mental health or substance abuse crises after hours. Each program has a nurse assigned who is also available 24 hours, 7 days per week. The residential program can house a maximum of 35 families, depending on the number of children in each family. The Cobb County program is more intensive in nature, and most services are on site. Stays in this location are from 6 to 12 months. After a successful stay in the Cobb County location, clients may be transferred to the Douglas facility, where their stay can be longer if the family is homeless. Clients at the Douglas facility stay an average of 9 months but can stay up to 2 years. The Douglas County program sends clients to the their day program for services.

The residential program is coordinated to provide services in three phases. The first phase (90 days of services at the Cobb County facility), known as the Ready to Work Program, focuses on overcoming the client's severe addiction. This first phase of intensive services to conquer addiction involves counselors being straight with clients about the realities of addiction and providing "tough love" guidance through spirituality and a 12 step drug recovery program. The first 60 days deal primarily with the client's denial behavior and teaching skills to enhance the development of recovery tools.

The second phase of the residential program lasts 4 to 6 months and involves substance abuse treatment, relapse prevention, self development, and skills building. This phase also focuses on family reunification. Services provided are primarily targeted toward enhancing life skills and include an array of substance abuse counseling, anger management, child development, parental skills, nutrition, and education, all provided at the Cobb County MMAC offices for outpatient services. Transportation for services, appointments for doctors and nurses, probation appointments, and court hearings are provided, and a random urine drug screening is conducted to ensure the client remains drug-free throughout treatment. Mothers receive information on the effects of substance abuse on babies. They view videos about babies born to drug-addicted mothers and learn about the different behavior these children may exhibit, such as withdrawal and passiveness. This information also illustrates to the mothers that many of the babies are able to outgrow their addiction and become healthy children, despite the fact that some may suffer lifetime emotional or neurological disorders. During this phase of treatment, the clients also take part in a family setting with other mothers and their children that provides a sense of belonging and support and prepares mothers to reunify with their children. Community activities include arts and crafts, field trips, monthly potluck meals, and "I Can" award celebrations to acknowledge client progress. Clients are also required to prepare personal journals and asked to complete at least three pages per week in the journal. Assistance and tutoring are available for those who need help reading or writing.

As stated earlier, the primary goal of the second phase is to reunify clients with their children and establish skills to preserve the family. Most women in the program are reunified with their children during this phase. MMAC then takes the responsibility of child care and transporting the child to school and health appointments. It is important to point out that once a child is reunified in the residential program with his/her parent, the parent acquires physical custody of the child, with the state maintaining legal custody of the child. The uniqueness in MMAC is that the parent and child are reunified while the mother is in residential treatment. For women not reunified, children are permitted to visit on weekends and overnight. MMAC understands how stressful visitation and the process of reunification can be on a mother. The program facilitates a total of 12-17 visitations per month for all clients and their children. Visitation is conducted as a gradual process and usually begins in hourly sessions, then overnight visits, 2-day visits, and so on. For women with multiple children, MMAC increases the number of children per visitation gradually as well. Clients also may be eligible for passes during the second phase of the program and are able to leave the facility for shopping or visits with relatives but must report back to their residence by a designated time.

Educational services are provided through MMAC's Education Program, run by one full-time staffer. The curriculum is designed as a self-help program, tailored for the individual to progress at her own pace. This program is detailed later under Day Treatment Services.

The third and final phase of the residential program consists of 6 months of after care that focus on support to avoid or minimize substance abuse relapses and finding employment for the client. The after-care phase involves very close monitoring of the parent's interaction with her children by MMAC's case manager and continued drug screenings, family enhancing, and educational and job activities. Transportation is provided for court or probation appointments, health care, employment training, and to work.

Day Treatment Services

The non-residential, day treatment program provides a variety of services to women and their families from 9 a.m. to 2 p.m., including substance abuse treatment, meals, transportation, case management, day care, parenting classes, health care and mental health services, substance abuse relapse prevention, education and GED courses, and employment services. Services are provided at the Cobb County offices. Individualized services can include therapy (individual and group); support groups; stress management; budgeting; team management; family education groups; exercise, self-esteem, anger, and domestic violence services; health education; nutrition; personal hygiene; and HIV education.

Educational services are provided on a 4-day class schedule. Monday and Wednesday are devoted to educational enrichment; Tuesday and Thursday focus on activities necessary to complete the GED; Friday is devoted to light educational games and fun learning activities. Clients' assignments are graded and homework assignments are given in GED-level coursework. The program is entitled "Reach and Teach" and is broken down into two separate components. The Reach component serves between 8 and 12 clients at one time, per group, and focuses on motivation, self-esteem and maintaining attention span. Incentives are provided to motivate students and self-esteem is cultivated by having students tutor their peers. Attention span activities include required-reading articles posted on a community bulletin board and reading articles from newspapers. Clients are also trained to use computers for word-processing and Internet access including how to use search engines. Students also volunteer for various activities.

The Teach component of the program has three tracks: 1) GED preparation, 2) Enrichment, and 3) Advanced. The GED preparation track includes instruction in language, math, spelling, algebra, and computer skills. Students practice on old GED tests and preparatory tests. Homework is assigned. To date, 99 percent of clients in this track have achieved their GEDs. The Enrichment track is for those clients who already have a high school diploma and want to learn additional skills or enhance existing skills. They receive instruction in reading, English, math, typing and word processing, as well as Internet skills. Assignments are graded. The Advanced track is for the few clients who have some college education or a college degree. The program utilizes students as peer tutors and provides instruction on topics of personal interest. One recent student learned to design a web page and received an award for her work. As part of the educational program, students also perform community services at senior center facilities, children's hospitals, or homeless shelters. It is interesting to note that around 30 former clients at MMAC facilities are currently employed with MMAC training and assistance, or with the County Community Service Board.

In addition to coursework, students are actively involved in planning "We Can" events to honor and celebrate their accomplishments. They plan celebrations such as luncheons and award ceremonies. Each has a theme. At the award ceremonies, students are recognized for various achievements, and a "Student of the Quarter" is chosen. The women find these activities exciting and look forward to the opportunity to have parents, children, and relatives attend. At the celebration events, themes dealing with cultural diversity are the focus, and activities have included a fashion show where clients wear apparel from different countries to a food court where clients make dishes from various parts of the world and explain the culture and food.

The educational program also sponsors general enrichment activities for clients during the week and weekends. Clients are encouraged to interact with their children at the onsite child care, attend substance abuse recovery meetings, and got to the library or purchase a book.

Outpatient Services

Outpatient services provide treatment for clients who meet the diagnostic criteria for substance-related disorder as defined by the DSM-IV. MMAC has two levels of outpatient services -- Level I, which includes assessment and individual, group, and family support services for less than 6 hours weekly, and Level II, which is more intensive and provides the same services for 9 or more hours per week. The length of services is based on individual needs, the client's treatment plan, and needed support. Services include individual therapy, group therapy, psychiatric assessment, medication monitoring, family therapy/support, nursing assessment, and family education/support. These services are geared toward women with children in foster care placement or at risk of TPR because they are most likely to enter the residential treatment program.

Outreach Services

MMAC also provides outreach services in the community. Outreach is an extension of MMAC services to the community. In recognition that many cultural groups, communities, and specialized populations will not readily seek a treatment facility, MMAC has staff who have established themselves in the community. Services are provided to pregnant women or women with young children, women with numerous hospital admissions, and women in shelters and other community agencies. MMAC hopes to accomplish education in the community, to encourage all cultural groups to enter services, and reduce and minimize barriers to treatment for groups and communities. This service is provided on a continuous basis 7 days a week and when there is a crisis that requires assistance.

Also a part of outreach services is providing substance abuse education to the community when requested. This may include speakers and participation in local health fairs to promote and increase awareness of substance abuse and related issues. Additionally, MMAC staff collaborate with community agencies to help enhance and coordinate the quality of care provided to the community.

Early Intervention Services

MMAC began providing early intervention services in June 2000. These services are provided to women at risk of developing substance related problems and are designed to explore and address risk factors that appear to be related to substance abuse and teach the client how to recognize harmful consequences of inappropriate substance use. The program is psycho-educational based and consists of components on the medical aspects of addiction, the dynamics of addiction, cross addiction, and coping skills. Services are prepaid at a cost of $125, which includes the group meetings and urine drug screenings. Appropriate clients include those referred to MMAC for assessment where the extent of abuse or addiction is unknown, those with a suspected history of substance use but in denial of active substance use, and cases in which assessment staff are unable to aptly diagnose under the DSM-IV guidelines.

Other Services

Health services are an important part of the comprehensive services provided by MMAC, with help and coordination from the DPH. Health services include basic health screening, family planning services, an early intervention program for infants in a high-risk population for developmental delay, a WIC program that provides food and nutritional counseling, and prenatal and postnatal care.

Child care services are also provided to clients and their families on site while the client attends treatment services. The availability of child care on site reduces a major barrier to treatment and reunification and provides a supervised site for the mother to develop and enhance her parenting skills.

Additional services that MMAC generally provides to clients include family education, community education and prevention services, and Beginning Alcohol and Addiction Basic Education Studies (BABES) for children of dysfunctional and substance-abusing families.