Previous chapters discussed the goals of alcohol and other drug (AOD) abuse treatment diversion programs and addressed the planning issues in developing these programs. This chapter provides a review of the basic activities required to implement a program for diverting appropriate AOD-abusing youth from the juvenile justice system (JJS) to appropriate AOD abuse treatment.
One way to facilitate the implementation of the program is for the planning group to develop a manual outlining each step required to establish a successful AOD abuse treatment diversion program. The implementation manual must clearly explain 1) lines of authority, 2) the functions and responsibilities of the AOD abuse treatment system, 3) linkages between community agencies and the JJS, and 4) methods by which the costs of treatment and referral services will be reimbursed.
This manual will document the purposes, goals, objectives, and intended activities of the program. It is an effective way to demonstrate that the program is endorsed by the key system components: the JJS; AOD abuse treatment services; community physical and mental health services and social services; and community representatives. Representatives of the collaborating groups will change over time and the individuals responsible for implementing a program may not have been involved in planning it. Development of an implementation manual will ensure that the program operations remain consistent with the decisions reached by the planning group.
Many types of information should be included in the implementation manual. The manual should provide clear, concise information to help everyone understand the goals and objectives of the diversion program as well as all system components, including referral organizations in physical and mental health and social services. Procedures for referral between agencies should be spelled out. Similarly, procedures for interagency dispute resolution should be described. The responsibility of the lead agency should be set forth clearly, and the manual should specify the sources of funds that will have to be obtained throughout the life of the diversion program and the procedures for obtaining these funds. Funding should be discussed early on; too many diversion program planners make the mistake of not focusing on obtaining new funding until it is too late.
The manual should describe the criteria for selecting youth eligible for admission to the AOD abuse treatment diversion program, along with screening and assessment procedures for youth identified as potential candidates for diversion to AOD abuse treatment. The continuum of services should be described and explained.
The following sections describe implementation steps that must be considered at each step. They are summarized in Exhibit 5-1.
Key leaders of the components within the various systems involved in the AOD abuse treatment diversion program must be active in both planning the program and implementing it. The first step in identifying key leaders is to contact the individual and agency stakeholders identified in Chapter 3. These are the persons and agencies most familiar with the various aspects of the problem (including representatives of juvenile court judges and services, parents and advocacy groups, persons with recent experience using the current system, law enforcement agencies, AOD prevention and treatment programs, community agencies, public and mental health centers, schools, business organizations, and other agencies that have contact with juveniles). Agencies can be asked to identify a contact person who has authority to commit agency resources to participate in developing the program.
The primary individuals and agencies involved in implementing a program for diverting AOD-abusing youths from juvenile court interventions are the same as those involved in planning, as described in Chapter 3: 1) the juvenile judge and the juvenile court; 2) the AOD abuse treatment system; and 3) community physical and mental health and social services. The JJS can use the legal power of the court to enhance treatment by effectively influencing or motivating the youth to engage in AOD abuse treatment and holding the youth -- and at times even the family -- accountable for doing so. AOD abuse treatment system players include providers in public programs, contractors operating AOD abuse treatment programs, representatives of single State agencies (SSAs), and private programs. Community physical and mental health services and social services providers include the public health department, private practitioners, child welfare agencies, child and family services, welfare services, and homeless programs. Representatives from the public health system can include hospitals, public health units, rural cooperatives, and county and State health departments. Other participants can include neighborhood groups (neighborhood and parent associations, including business and religious communities) and the educational community.
In times when funding may be limited or nonexistent, communities are going to have to address obtaining funding in creative and innovative ways. There are several scenarios for obtaining funding. One approach is to first explore funding services, design a program, and then formally request funds for it. Another way is to obtain startup funding in order to develop a program, then obtain more funding to implement the program. Another is to obtain the funding, then design and implement the program. A fourth, useful in obtaining potential funding, is to get agencies to commit part of their budgets to supporting the program. Obtaining funding is not a one-time event but a continuing activity. Different communities, agencies, and funding entities have different ways of funding programs and services. Although securing funds is second on the checklist, it is an activity that needs to go on throughout the life of the project.
Obtaining funding is not a one-time event but a continuing activity.
Funding mechanisms may include the assessment of fees from program participants, allocation of assessments or a percentage of fines imposed on AOD-related crimes, proceeds from drug forfeiture (sales of dealers' assets, handled through Federal and local law enforcement), private insurance, license fees, government and private foundation grants, private funds (for example, from the business sector), community matching funds, and untraditional resources. Opportunities created as a result of healthcare reform, refinancing, and restructuring should also be explored. Funding issues affect treatment choices but should be driven by the specific continuum needed. The implementation manual should provide a clear discussion of the pros and cons of resource allocation.
Because in most jurisdictions the juvenile court is the focal point of all agencies involved with youth in the JJS, the role of the juvenile court judge will be vital, and he or she should take an active lead in convening the stakeholders in the implementation process.
The intent of programs designed to divert selected AOD-abusing youth from the JJS is stated in the prospectus for this Treatment Improvement Protocol (See Appendix H):
Justice systems that have interventions that provide habilitative conditions for juvenile offenders and their families can work to divert from the justice system a population of young offenders who are at risk for later committing criminal acts associated with their substance use disorder. The Juvenile Justice field has great need for such interventions with youth who are initially status offenders or who have experienced previous adjudication for lesser offenses and are at significant risk for criminal activity. . . . Effective treatment of substance use disorders among adolescents requires a comprehensive approach that incorporates family and health issues. A holistic approach to the treatment of adolescents may obviate their future involvement in status offenses or delinquent or criminal activity.
The goals and objectives for AOD diversion will vary from locale to locale, depending on such factors as State laws, local attitudes about crime and punishment, local attitudes about AOD abuse, and the availability of local AOD abuse treatment resources for juveniles. The mission statement can help unify the many organizations involved in diversion program planning and implementation.
Goals and objectives can be established, taking care that the results of program activities can be measured and evaluated. An effective program might have the following goals and objectives:
- All youth eligible for diversion to AOD abuse treatment will be identified and appropriately placed, using screening and assessment:
- Screening will be conducted to identify youth for whom further assessment is indicated.
- Assessment will be conducted by a qualified assessor.
- Screening and assessment will be available at a number of convenient locations.
- The youth will be placed in the type of treatment program suggested by the assessment results.
- Each youth will have a single, individualized treatment plan based on his or her needs rather than on the availability of AOD abuse treatment slots:
- A single case manager will be assigned to each.
- Every youth will receive appropriate AOD abuse treatment services, as well as physical health, mental health, and social services as needed.
- Appropriate continuing care and relapse prevention will be provided to help ensure the recovery of the youth. The treatment plan will include plans for continuing care and relapse prevention.
- The AOD abuse treatment diversion program will be evaluated and revised as suggested by the evaluation.
Effective communication among agencies and systems is critical to the success of any diversion program and must be continuous. The implementation manual should describe how to ensure that appropriate linkages are established. Linkages may include written agreements or memoranda of understanding, as well as interagency coordination, interagency training, liaison with community organizations, and other forms.
Conflicts can arise regarding issues, both broad (participant agency authority, responsibility, information sharing, and funding distribution) and specific (interagency disputes over eligibility criteria or modification thereof). To assist in resolving such conflicts, a dispute resolution mechanism must be devised, agreed upon by all groups involved, and documented.
For example, an interagency committee with representatives from major agencies involved in the diversion program could serve as a mediator for such disputes, with the juvenile court designated as the final arbiter on the issue of juvenile accountability. By focusing on agency understanding and response to issues having a significant impact on juveniles and families and initiating the often difficult process of debate and action, it should be possible to resolve most issues without juvenile court intervention.
As discussed in the previous chapters, the selection criteria (eligibility guidelines) for youth entering the AOD abuse treatment diversion program must be documented clearly and disseminated to all key stakeholders in the participating systems. The eligibility criteria should include the juvenile's age, educational background, and level of sophistication and maturity, as well as consideration of the nature and history of the juvenile's offending conduct, any statutes that may preclude a particular juvenile from participating in diversion, the juvenile's amenability to treatment (and amenability to sharing information within the diversion system), the nature and extent of the AOD problem, previous court contact (history), and previous AOD abuse treatment diversion experience. It may be necessary to distinguish amenability to treatment from recognition of the drug problem, since some juveniles will be in denial. Diversion should be voluntary, so there must be a willingness on the juvenile's part to be diverted and to participate in AOD abuse treatment.
The implementation manual must provide clear eligibility guidelines that will ensure, at a minimum, that the youth has an identified AOD use problem, qualifies for treatment, is not a threat to the safety of the community, can be held accountable through the means of AOD abuse treatment program participation, and will have access to appropriate treatment.
The eligibility criteria should include the juvenile's age, educational background, sophistication, and maturity level as well as consideration of the history of the juvenile's offending conduct, any statutes that may preclude a particular juvenile from participating in diversion, the juvenile's amenability to treatment, the nature and extent of the AOD abuse problem, previous court contact, and previous AOD abuse treatment diversion experience.
The implementation manual should describe a grievance process specifically related to the appropriateness of eligibility determinations, the level and type of treatment provided, termination of eligibility, and other issues. Grievance procedures might include establishing an investigatory process; developing a mediation process; designating a staff person responsible for reviewing complaints, the youth's family, or guardian ad litem (for the particular action or proceeding) regarding treatment and eligibility (a complaint investigator); and establishing an appellate panel with representatives from participating agencies. It is also necessary that each participating agency have clearly articulated grievance and complaint procedures for internal use.
There must be a balance between sharing information on a "need-to-know" basis with those who make treatment decisions and with the court, which must monitor the process, while still protecting the youth's rights to confidentiality. The implementation manual should describe the methods or strategies for establishing this balance and developing information-sharing guidelines, while keeping in mind confidentiality laws, privilege laws, and ethical considerations. The manual should include a discussion of the appropriate levels of information to share. The manual also should include guidelines for informing treatment programs how to share information with the court in accordance with Federal and State confidentiality rules. These guidelines need to apply at the individual case level as well as at the systemic level.
The implementation manual should also include information regarding Federal and State confidentiality statutes and instructions on how to expand them to AOD abuse treatment providers in order to facilitate appropriate information sharing.
Court-mandated treatment plans, to be effective, must be monitored to ensure that the juvenile and family are participating as required and that the AOD abuse treatment diversion is meeting their needs. The implementation manual should provide guidelines or protocols for ensuring the consistent sharing of information in a collaborative way between AOD abuse treatment providers and the JJS. Such guidelines will assure that the juvenile court judge, individual juvenile court case managers, and other appropriate interested parties are aware of the array of information-sharing concerns affecting AOD abuse treatment of diverted juveniles.
Timely access for eligible juveniles to screening and assessment is essential for effective implementation of AOD abuse treatment diversion. "Timely" in this context means at the earliest possible opportunity -- during the intake process. What constitutes "timeliness" should be defined in the implementation manual and should be based on the needs of youth, the availability of AOD abuse treatment resources, and organizational constraints.
Some States have statutorily mandated time limits for court-ordered medical or mental health examinations or studies after a youth is placed in custody. Other States do not have any time constraints between custody, custody hearings, adjudication, and disposition. In those States where there are no such time limits, the implementation manual should establish guidelines to ensure that the court has access to information and that the juvenile has access to treatment as soon as possible.
The implementation manual should include a discussion of the appropriateness or usefulness of offering the youth (or parent) the opportunity to waive the right to a speedy trial. For example, in some States it is required that a juvenile in detention have the first hearing within 48 hours of detention. If the juvenile is detained in custody, the case may have to be adjudicated within 14 days. The time between the formal filing (petition) and adjudication varies; the implementation planning group should consider any requirements associated with scheduling.
A potential barrier to quick access may be the time associated with case processing in the local juvenile court. The implementation manual must address case processing concerns in the local juvenile court system and whether improvements can be made. The National Council of Juvenile Family Court Judges' Alcohol and Substance Abuse Committee (1994) recommends that courts intervene as early as possible (as early as the judicial process permits) whenever they determine that AOD abuse is an issue in a case. Therefore, screening and assessment for appropriateness of diversion to AOD abuse treatment should take place as early as possible. This process is also necessary to increase the effectiveness of treatment. Screening should take place at intake, but an exact "timeline" for assessment is impossible to determine because timing depends on when the case is going to court.
The implementation manual should list and describe the ideal continuum of services for the effective treatment of AOD-abusing juveniles in the community. This continuum of treatment services should be determined based on AOD abuse demographics and should cite all agencies to which referral may be made for needed healthcare or social services.
The manual should also contrast the ideal continuum with what is actually available in terms of AOD abuse treatment for youth. This contrast involves identifying the resources available from assessment through the various levels of treatment, establishing a directory of services (for example, a resource book), and establishing relationships with the programs and facilities within or closest to the planning region.
The difference between the ideal continuum and the real continuum represents the gaps in AOD abuse treatment services available to the community. In addition to describing clearly how to gain access to existing resources, the implementation manual should describe how to develop resources to fill the gaps identified in AOD abuse treatment services. Gaps in the local AOD abuse treatment continuum may be bridged by establishing innovative relationships between providers or by tapping into AOD abuse treatment resources available in surrounding communities. As always, the goal should be to place juveniles in AOD abuse treatment as close to home as possible. It may also be necessary to reallocate funding based on the gaps identified in AOD abuse treatment services for youth.
The difference between the ideal continuum and the real continuum represents the gaps in AOD abuse treatment services available to the community. These gaps may be bridged by establishing innovative relationships between providers or by tapping into AOD abuse treatment resources available in surrounding communities.
To combine diversion with AOD abuse treatment successfully requires accountability on a number of levels -- personal accountability on the part of the youth, system accountability on the part of the participating system components and referral agencies, and assurances of treatment integrity and effectiveness. The issue of holding youth accountable is particularly critical in an AOD abuse treatment program for youth diverted from the JJS. AOD abuse treatment must be a reasonable, active accountability approach to traditional juvenile court sanctions. It cannot be perceived (by the youth or the community) as a means of avoiding personal responsibility. Addressing system accountability ensures that the concept of combining diversion and AOD abuse treatment is a legitimate one. Effective measures of treatment outcomes will demonstrate whether the community is being served adequately by the diversion of offending youth to AOD abuse treatment.
The evaluation plan is an integral part of the diversion program, as important as the initial screening and assessment process. It must be based on outcome measures for assessing the effectiveness of system collaboration, the quality of provider services, and the impact they have on the individual juvenile in the diversion program.
The implementation manual must include a well-designed evaluation plan that addresses both process (Is the program operating as envisioned?) and outcome measures (Are we getting the results that we had anticipated?). It must be comprehensive in design, encompassing the whole system. A number of evaluation elements must be set forth unambiguously, including the type of data to be collected, evaluation models to be used, and means to be used to track the success of the juvenile over time.
The evaluation design must be sensitive to the entire diversion process. Existing data collection systems must be linked to the accountability system. The implementation manual can describe methods and strategies for accessing required information.
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