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Center for Substance Abuse Prevention (US). Addressing Fetal Alcohol Spectrum Disorders (FASD). Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 58.)

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Addressing Fetal Alcohol Spectrum Disorders (FASD).

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Chapter 2Building an FASD Prevention- and Intervention-Capable Agency

Introduction

The resources presented in this chapter have been organized into those related to organizational assessment and those related to planning and implementing organizational change. The change process in your agency or program will require creative and thoughtful adaptation and application of these resources to your specific circumstances. They should be viewed as points of departure only. You should revise or otherwise modify the materials as needed for your organization.

You may also wish to consult with colleagues who have managed organizational change in organizations similar to yours. At this point in the development of implementation strategies for human services, many excellent ideas are still to be found outside the published literature. Your colleagues may have insights or ideas that are equal to or more applicable than those presented in this Implementation Guide.

The Change Book, produced by the Addiction Technology Transfer Center (ATTC) Network, provides the basis for the organizational change process presented in TIP 48 and in this TIP. The page numbers referenced in this chapter refer to the Second Edition, 2010, which can be downloaded for free from the ATTC Network (www.attcnetwork.org) in English or Spanish (http://www.attcnetwork.org/explore/priorityareas/techtrans/tools/changebook.asp).

Additionally, you may wish to consult Implementation Research: A Synthesis of the Literature (Fixsen et al., 2005; http://cfs.cbcs.usf.edu/docs/publications/NIRN Monograph Full.pdf). This monograph provides a valuable summary of the scientific basis for various implementation practices.

Another resource is SAMHSA's TAP 31, Implementing Change in Substance Abuse Treatment Programs (CSAT, 2009).

Assessment and Planning Before Implementation

How Do You Decide Whether to Implement a Policy for Addressing FASD?

To determine whether it makes sense for your agency to implement the recommendations made in Part 1 of this TIP, refer to Figure 2.1.

Each of the steps in this figure tie to the How-To's throughout this chapter.; Step A: Have you identified an issue or problem? If No, refer to How-To 2.1. If Yes, move on to Step B.; Step B: Have you identified the evidence that supports the existence of this issue or problem? If No, refer to How-To 2.1. If Yes, move on to Step C.; Step C: Have you identified the current practices for staff and administration that might be contributing to or maintaining this problem? If No, refer to How-To 2.2. If Yes, move on to Step D.; Step D: Has a team been identified to lead the preparation and implementation plans? If No, refer to How-To 2.3. If Yes, move on to Step E.; Step E: Do you have appropriate oversight and input to support implementation? If No, refer to How-To 2.3. If Yes, move on to Step F.; Step F: Has the specific outcome targeted for change been identified? If No, refer to How-To 2.4. If Yes, move on to Step G.; Step G: Have you addressed the agency? If No, refer to How-To 2.5. If Yes, move on to Step H.; Step H: Have you addressed the specific audience? If No, reassess the specific needs of the audience. If Yes, move on to Step I.; Step I: Do you have the information necessary to show that your agency will benefit from implementing this approach? If No, refer to Part 1, Chapter 1 of this TIP. If Yes, move on to Step J.; Step J: Does implementing this approach have the support of senior leadership? If No, refer to the NATTC Change Book, Step 6. If Yes, proceed with change planning.

Figure 2.1

Decision Tree. How to Decide Whether to Implement a Policy for Addressing FASD Each of the steps in this figure tie to the How-To's throughout this chapter. (For instance, Steps A and B tie to How-To 2.1, below.)

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How-To 2.1

How to Identify the Issue or Need (Figure 2.1, Steps A and B). Research suggests that the following issues or problems may be relevant to your agency's treatment outcomes. Think about the three levels where change can occur (i.e., program/organizational, (more...)

Checklist 2. Characteristics and Competencies of All Clinical Staff.

Checklist 2

Characteristics and Competencies of All Clinical Staff.

How Do You Identify the Issue or Need?

The How-To components on the following pages provide ways to operationalize the steps presented in Figure 2.1.

How Do You Assess the Capacity of the Agency to Provide FASD Prevention and Intervention?

Individuals with an FASD may see themselves as not fitting in, may be hostile or act out, and may struggle with multiple directions and tasks. Is this addressed in your treatment program? For example, are people failing to make appointments with no clear explanation of why? Speaking at the wrong time during group sessions? Or consistently completing only a portion of the treatment tasks they're given? In terms of prevention, is your program serving pregnant women and/or women of childbearing age? Are these women being asked about their alcohol consumption? Are they being made aware of the risk of FASD? Assess the current capacity of your agency or program to deliver FASD prevention and intervention (see How-To 2.2).

How Do You Organize a Team to Address the Problem?

Once you have identified an issue or problem, you need to create a workgroup to address the problem (see How-To 2.3).

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How-To 2.3

How to Organize a Team to Address the Problem (Figure 2.1, Steps D and E). Identify one person to lead the effort. Many programs that have successfully implemented programming for individuals with an FASD were able to do so because there was one committed, (more...)

How Do You Identify a Specific Outcome to Target for Change?

Once you've organized a workgroup to address the problem, you need to identify a specific outcome to be targeted for change (see How-To 2.4).

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How-To 2.4

How to Identify a Specific Outcome to Target for Change (Figure 2.1, Step F). Begin with the issue or problem identified in Step A of Figure 2.1, and determine a specific variable that can be measured that is directly related to improving the management (more...)

How Do You Decide Where to Start?

Once you've identified a specific outcome or outcomes to target for change, you will want the workgroup to assess the agency and the staff (both frontline and supervisory) to be targeted by the implementation. You will have an easier time implementing your plan if you start with a small program where staff members already work well with one another and believe in the new techniques. Staff members on closely knit teams work with one another's strengths and will have an easier time assigning responsibilities when it comes time to implement the practice. Alternatively, you may choose a small, core group of staff members who are ready to try new techniques and are prepared to be part of an implementation process (i.e., target early adopters across programs). These will be the first staff members trained and coached in using these techniques. Other advantages to starting small include the following:

  1. It is easier to track the success of the implementation.
  2. It is easier to identify and make any modifications to the techniques that may be necessary to accommodate the agency's clientele.
  3. The core group members will talk about the success they are having with the techniques and get other staff interested in learning and using the techniques.

For more information on assessing your agency's readiness for implementation, see How-To 2.5.

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How-To 2.5

How to Assess the Agency's Organizational Readiness for Implementation (Figure 2.1, Step G). The committee assesses the agency's organizational readiness by first determining whether implementing practices to improve the management of FASD in the agency's (more...)

Addressing Policies and Procedures

Although varying in format and structure as a result of regulatory and organizational diversity, policies and procedures serve as the foundation of organizational practice. Planning and implementing a new program component almost always impacts existing policies and procedures, but those same policies and procedures constitute one of the most common and effective mechanisms for institutionalizing organizational practices. As such, they will need to be reviewed and adapted to be sure they are in conformance with the new program.

Modifying Existing Policies

In addition to adopting policies on addressing FASD, provider agencies might consider modifying other policies and program descriptions to provide continuity of care for (1) women who are or may become pregnant who screen positive for at-risk drinking, and (2) individuals who have or may have an FASD.

For example, each program will develop its own approach to screening and monitoring for FASD based on (a) the characteristics of its clientele; (b) its resources, especially its staff training and background; (c) legal and reimbursement considerations; and (d) other factors unique to your agency (e.g., specific arrangements worked out with referral resources or consultants, participation in clinical trials, or other external influences). Your professional input into developing the necessary policies and procedures is essential, and at a minimum there should be a protocol that stipulates:

  • What standard questions a client is asked, when they are asked (by interview and/or self-report mechanisms), and when they should be repeated (especially what observations or events might trigger a fuller evaluation for an FASD)—These elements of the protocol should use published, reliable tools as discussed in Part 1 and the Literature Review for this TIP (Appendix C, Public and Professional Resources on FASD, contains useful links to sites where tools can be accessed);
  • Who can ask these questions and what training is provided or needed regarding the questions and the overall process, procedures, and policies;
  • Exactly how scoring or assessment of the clients' responses will be done, including exact guidelines for the follow-up triggered by various responses;
  • Where these policies and procedures fit within the agency's policies and procedures and what chain of command and communication exist;
  • How long AEP screening and prevention and/or treatment modification for FASD intervention will typically take, which will help you calculate how many interventions one staff member can realistically accomplish per day, anticipate staffing requirements for the project, and project potential income (consult with your administration and billing department—billing for both Medicaid and private insurance may require an intervention of at least 15 minutes' duration);
  • How personnel will obtain necessary training, forms, or materials;
  • How FASD-informed prevention and/or intervention will be introduced to the client (it might be helpful to have introductory statements worked out and written down in advance, and available to all staff); and
  • How FASD prevention and/or intervention will be documented, whether as written or electronic medical record documentation.

This section provides six samples of critical policies and procedures related to addressing FASD prevention and intervention within substance abuse treatment and mental health agencies. In each topic area, a policy statement and set of procedures related to the topic are presented. These sample policies can be used as presented, combined into one or more comprehensive policies, or integrated into the organization's existing policies. Each policy is divided into an example of a policy statement and a set of procedures, as the language will differ depending on whether an agency is revising policies to incorporate FASD intervention or FASD prevention.

Sample Policy 1a

Topic: Clinical staff training and competency [FASD intervention].
Policy Statement: All clinical staff will demonstrate basic competency in identifying signs of an FASD.
Procedures:
  1. All clinical and support staff will participate in a 3–5 hour training session covering FASD, the impact of these disorders on treatment, retention, and outcomes, and criteria and procedures for referring individuals to services aimed at formally diagnosing and addressing FASD. (See Appendix C, Public and Professional Resources on FASD, for training resources.)
  2. The clinical supervisor of new employees will provide site-specific information on the procedures for screening and referring individuals who exhibit signs of a possible FASD.
  3. Clinical competency checklists completed at hire and annually thereafter will ensure that all clinical staff members have a basic knowledge of FASD, an understanding of strategies for assessing the significance of FASD, and an awareness of appropriate referral procedures.

Sample Policy 1b

Topic: Clinical staff training and competency [FASD prevention].
Policy Statement: All clinical staff will demonstrate basic competency in screening women of childbearing age (whether pregnant or not) for alcohol consumption.
Procedures:
  1. All clinical and support staff will participate in a 3–5 hour training session covering FASD, the impact of alcohol on a fetus, and (if necessary) criteria and procedures for referring women who screen positive for at-risk drinking to appropriate services. (See Appendix C, Public and Professional Resources on FASD, for training resources.)
  2. The clinical supervisor of new employees will provide site-specific information on the procedures for screening and referring women who screen positive for at-risk drinking.
  3. Clinical competency checklists completed at hire and annually thereafter will ensure that all clinical staff members have a basic knowledge of FASD, an understanding of strategies for assessing the dangers of alcohol consumption for women of childbearing age, and an awareness of appropriate referral procedures.

Sample Policy 2a

Topic: Recruitment, training, and supervision of FASD-capable clinical staff [FASD intervention].
Policy Statement: Counselors interested in providing FASD-informed care and who possess the relevant basic counseling skills, knowledge, and attitudes (see Checklist 2, Characteristics and Competencies of All Clinical Staff, this chapter) will be recruited, trained, and supervised to deliver these interventions.
Procedures:
  1. At least one clinical position in each program or modality of care will be designated to provide FASD-informed care.
  2. Individuals exhibiting the attitudes, knowledge, skills, and job performance required to provide FASD-informed care will be identified by their clinical supervisor and designated to provide these services.
  3. The counselors identified to provide FASD-informed care will receive an initial training and additional “update” training each year in some or all of the following areas (see Appendix C, Public and Professional Resources on FASD, for training resources):
    • Fundamentals of FASD, including the effect of alcohol on the developing fetus and typical cognitive and behavioral impact across the lifespan.
    • Summary of current literature on FASD intervention, and on scientifically validated FASD intervention approaches.
    • Adapting treatment approaches for individuals with an FASD.
    • Talking with individuals with an FASD about their diagnosis.
    • Planning for client safety.
    • Principles of trauma-informed care.
    • Providing a “hands-on hand-off” approach to outside services (i.e., not simply making a referral and assuming that the client takes the appropriate action).
    • Addressing FASD in the context of cultural competency.
    • Building client self-efficacy and self-advocacy
    • Client-centered care.
    • Motivational interviewing.
    • Targeted provider and school consultation.
    • Personal boundaries and professional ethics.
    • Termination, referral, and discharge planning.
    • Appropriate community linkages.
    • Anticipatory guidance and planning for the future.
  4. Counselors providing FASD-informed care will receive clinical supervision twice monthly that includes direct observation or review of tapes of individual sessions with clients who have or may have an FASD.
  5. Counselors providing FASD-informed care will meet quarterly to provide peer support, supervision, and share resources related to the management of clients who have or may have an FASD.

Sample Policy 2b

Topic: Recruitment, training, and supervision of clinical staff capable of screening women of childbearing age (whether pregnant or not) for alcohol consumption [FASD prevention].
Policy Statement: Counselors interested in providing alcohol screening and referral and who possess the relevant basic counseling skills, knowledge, and attitudes (see Checklist 2, Characteristics and Competencies of All Clinical Staff, this chapter) will be recruited, trained, and supervised to deliver these interventions.
Procedures:
  1. At least one clinical position in each program or modality of care will be designated to provide alcohol screening to women of childbearing age.
  2. Individuals exhibiting the attitudes, knowledge, skills, and job performance required to provide alcohol screening will be identified by their clinical supervisor and designated to provide these services.
  3. The counselors identified to provide alcohol screening will receive an initial training and an additional update training each year in some or all of the following areas (see Appendix C, Public and Professional Resources on FASD, for training resources):
    • Fundamentals of FASD, including the effect of alcohol on the developing fetus and typical cognitive and behavioral impact across the lifespan.
    • Summary of current literature on FASD intervention, and on scientifically validated FASD intervention approaches.
    • Planning for client safety.
    • Principles of trauma-informed care.
    • Providing a ‘hands-on hand-off’ approach to outside services (i.e., not simply making a referral and assuming that the client takes the appropriate action).
    • Addressing FASD in the context of cultural competency.
    • Building client self-efficacy and self-advocacy
    • Client-centered care.
    • Motivational interviewing.
    • Targeted provider consultation.
    • Personal boundaries and professional ethics.
    • Termination, referral, and discharge planning.
    • Appropriate community linkages.
    • Anticipatory guidance and planning for the future.
  4. Counselors providing alcohol screening will receive clinical supervision twice monthly that includes direct observation or review of tapes of individual sessions with female clients of childbearing age.
  5. Counselors providing FASD-informed care will meet quarterly to provide peer support, supervision, and share resources related to providing alcohol screening to female clients of childbearing age.

Sample Policy 3a

Topic: Observation and referral of clients exhibiting signs of an FASD [FASD intervention].
Policy Statement: The possible presence of an FASD will be considered with all noncompliant or resistant or ‘problem’ clients, and possible indicators will be noted through a process of observation and interviewing. Clients exhibiting signs of a potential FASD will be referred as needed.
Procedures:
  1. During intake and throughout the early stages of treatment (i.e., first month), all clients exhibiting persistent (and otherwise unexplained) noncompliance with treatment will be observed, and the individual's case history reviewed, for FASD “indicators” based on a checklist (see the FASD 4-Digit Code Caregiver Interview Checklist in Part 1, Chapter 2 of this TIP).
  2. Individuals exhibiting signs of an FASD will either be assessed by an identified in-house team with FASD expertise or be referred to an accepted FASD evaluation agency.
  3. With or without a formal diagnosis of FASD, a client exhibiting signs of an FASD will be referred to a counselor competent in providing FASD-informed care and capable of modifying treatment to account for the observed behavioral/cognitive deficits (see Sample Policy 2).
  4. All screening results, consultation sessions with the clinical supervisor, and referrals (and ongoing communications) to an FASD evaluation agency will be documented in the client's record.
  5. The counselor providing FASD-informed care will provide the client with an emergency contact list that includes agency personnel and emergency care providers. The client can refer to this list if he or she has treatment or safety issues outside business hours or when a counselor is not available. (See Appendix F for a Sample Crisis/Safety Plan that can be filled out with clients.)

Sample Policy 3b

Topic: Screening and referral of female clients of childbearing age exhibiting signs of an alcohol use/abuse [FASD prevention].
Policy Statement: All women of childbearing age (whether pregnant or not) will be screened for alcohol consumption and referred as needed.
Procedures:
  1. During the intake process, all women of childbearing age will be screened for alcohol consumption.
  2. Staff will be trained in using specific alcohol screening tools that are validated for use with women, such as the T-ACE or TWEAK (for pregnant women), the AUDIT-C Questionnaire (nonpregnant women), or the CRAFFT Interview or FRAMES (with adolescent and young adult clients).
  3. Individuals screening positive for at-risk alcohol consumption will receive an appropriate assessment or be referred for one, to be conducted by a qualified substance abuse treatment professional.
  4. Clients who are determined by a qualified substance abuse treatment professional to have an alcohol-related disorder will receive or be referred for substance abuse treatment, also to be delivered by that professional. Collaborative relationships with appropriate providers will be developed.
  5. All women of childbearing age will receive FASD-related education (pamphlet, suitable Web site, etc.), whether pregnant or not and whether screening positive for at-risk alcohol consumption or not.
  6. All screening results, consultation sessions with the clinical supervisor, and referrals (and ongoing communications) to a qualified substance abuse treatment professional will be documented in the client's record.
  7. The counselor providing substance abuse treatment will provide the client with an emergency contact list that includes agency personnel and emergency care providers. The client can refer to this list if she has treatment issues outside business hours or when a counselor is not available. (See Appendix F for a Sample Crisis/Safety Plan that can be filled out with clients.)

Sample Policy 4a

Topic: Treatment planning, service recording, discharge planning, and continuity of care [FASD intervention].
Policy Statement: Management of FASD will be integrated with substance abuse/mental health services, be properly documented, and include appropriate discharge and transfer planning.
Procedures:
  1. Screening and observation for signs of an FASD and—when indicators are present—strategies for addressing FASD will be included in the client's treatment plan.
  2. Treatment plans incorporating FASD management will be jointly developed by the interdisciplinary team and the client within and/or across programs.
  3. To minimize client confusion, the client will be provided with information about the roles and responsibilities of those delivering care.
  4. Treatment plans will include referral to other community resources and peer support activities that may increase the client's self-efficacy and reduce FASD-related treatment barriers.
  5. Interdisciplinary treatment update sessions including all professionals involved with the client's care should occur regularly. (The frequency of treatment plan updates should be consistent with state and organizational standards and will vary by modality of care and regulatory agency.) Ideally these would be held weekly for short-term residential treatment and monthly for long-term residential treatment and outpatient settings.
  6. Services delivered by the primary counselor will be recorded in the client's record at each contact and will be available to other members of the treatment team.
  7. Major changes in the client's condition or treatment compliance/success will be communicated between the primary counselor and the interdisciplinary team.
  8. The checklist of FASD “indicators” (see Sample Policy 3) will be completed at the last session before termination to assist in developing the discharge plan and to be used by the quality assurance department for outcome monitoring.
  9. Discharge and transfer planning will include recommendations for the client about self-care, self-advocacy, and other available FASD-informed services that are available to them.

Sample Policy 4b

Topic: Treatment planning, service recording, discharge planning, and continuity of care [FASD prevention].
Policy Statement: Treatment for at-risk alcohol consumption among all women of childbearing age (whether pregnant or not) will be integrated with substance abuse/mental health services, be properly documented, and include appropriate discharge and transfer planning.
Procedures:
  1. Screening for alcohol consumption among all women of childbearing age (whether pregnant or not) and strategies for addressing the client's alcohol use will be included in the client's treatment plan.
  2. Treatment plans incorporating alcohol use management will be jointly developed by the interdisciplinary team and the client within and/or across programs.
  3. To minimize client confusion, the client will be provided with information about the roles and responsibilities of those delivering care.
  4. Treatment plans will include referral to other community resources and peer support activities that may increase the client's self-efficacy and reduce alcohol consumption.
  5. Interdisciplinary treatment update sessions including all professionals involved with the client's care should occur regularly. (The frequency of treatment plan updates should be consistent with state and organizational standards and will vary by modality of care and regulatory agency.) Ideally these would be held weekly for short-term residential treatment and monthly for long-term residential treatment and outpatient settings.
  6. Services delivered by the primary counselor will be recorded in the client's record at each contact and will be available to other members of the treatment team.
  7. Major changes in the client's condition or pattern of alcohol use (or simply changes in alcohol use, if this is the primary objective of treatment) will be communicated between the primary counselor and the interdisciplinary team.
  8. An appropriate alcohol screening tool agreed upon by the interdisciplinary team will be completed at the last session before termination to assist in developing the discharge plan and to be used by the quality assurance department for outcome monitoring.
  9. Discharge and transfer planning will include recommendations for the client about self-care, self-advocacy, and other alcohol use support services that are available to them.

Sample Policy 5a

Topic: Counselor performance appraisal [FASD intervention].
Policy Statement: Counselors capable of providing FASD-informed services will have job descriptions that include a high level of specific performance expectations related to provision of services for these clients.
Procedures:
  1. Job descriptions for counselors agreeing/qualified to provide FASD intervention services may include reduced caseload and productivity expectations, particularly during an agreed-upon early stage of implementation.
  2. Performance appraisal of counselors providing FASD intervention services will include demonstration of relevant core competencies (e.g., as observed directly and/or through videotaping).
  3. Annual training requirements will be outlined in the job descriptions of counselors identified to provide FASD-informed services.
  4. Client satisfaction surveys and outcome reports will be discussed in performance evaluations with counselors providing FASD intervention services. Such evaluations may need to occur more regularly than annually when implementing new practice.

Note: The following sample policy is potentially more relevant in mental health treatment settings than in substance abuse treatment settings, as alcohol use management services are a core competency in substance abuse treatment and presumably would not be separated out in a policy statement in this fashion.

Sample Policy 5b

Topic: Counselor performance appraisal [FASD prevention].
Policy Statement: Counselors capable of providing alcohol consumption screening for women of childbearing age (whether pregnant or not) and appropriate services/referral will have job descriptions that include a high level of specific performance expectations related to provision of services for these clients.
Procedures:
  1. Job descriptions for counselors agreeing/qualified to provide FASD prevention services may include reduced caseload and productivity expectations, particularly during an agreed-upon early stage of implementation.
  2. Performance appraisal of counselors providing FASD prevention services will include demonstration of relevant core competencies (e.g., as observed directly and/or through videotaping).
  3. Annual training requirements will be outlined in the job descriptions of counselors identified to provide alcohol use management services.
  4. Client satisfaction surveys and outcome reports will be discussed in performance evaluations with counselors providing FASD prevention services. Such evaluations may need to occur more regularly than annually when implementing new practice.

Sample Policy 6a

Topic: Evaluation of service effectiveness and quality assurance [FASD intervention].
Policy Statement: Services for addressing FASD will be reported annually through the agency's quality assurance system along with indicators of effectiveness based on client outcomes.
Procedures:
  1. The agency's quality assurance program will include monitoring the implementation of policies related to FASD screening and treatment modifications, FASD evaluation referral procedures, documentation and treatment planning, and supervision of counselors providing FASD-informed services.
  2. Data from admission and discharge screening of clients exhibiting FASD “indicators” (see Sample Policy 3) will be aggregated by the quality assurance coordinator for annual reporting to the agency.
  3. The following overall agency performance outcomes will be reviewed annually by the management team:
    1. The proportion of clients dropping out of treatment before the third session after implementation of FASD-informed services, or appropriate length of time based on your agency's treatment schedule (it will be important to have information on the dropout rate after implementation to assess the impact of these services on treatment engagement and retention).
    2. The number of clients receiving FASD-informed services, as a percentage of overall client population.
    3. The number of clients referred to an FASD evaluation agency, as a percentage of overall client population.
    4. A comparison of (1) the proportion of all clients experiencing a relapse during treatment, and (2) the proportion of all clients receiving FASD-informed care that experience a relapse during treatment.

Note: As with sample policy 5b, the following sample policy is potentially more relevant in mental health treatment settings than in substance abuse treatment settings, as alcohol use management services are already a core competency in substance abuse treatment.

Sample Policy 6b

Topic: Evaluation of service effectiveness and quality assurance [FASD prevention].
Policy Statement: Services for managing alcohol use consumption among women of childbearing age (whether pregnant or not) will be reported annually through the agency's quality assurance system along with indicators of effectiveness based on client outcomes.
Procedures:
  1. The agency's quality assurance program will include monitoring the implementation of policies related to alcohol use management among women of childbearing age (whether pregnant or not), substance abuse treatment referral procedures, documentation and treatment planning, and supervision of counselors providing alcohol use management services.
  2. Data from admission and discharge screening of clients who are women of childbearing age and have received alcohol use management services (see Sample Policy 3) will be aggregated by the quality assurance coordinator for annual reporting to the agency.
  3. The following overall agency performance outcomes will be reviewed annually by the management team:
    1. The proportion of clients who receive screening for at-risk alcohol use who subsequently drop out of treatment, as a comparison with clients who do not receive this screening and subsequently drop out of treatment.
    2. The proportion of these clients evidencing at-risk alcohol consumption at both admission and discharge.
    3. The number of clients who are women of childbearing age who receive screening for at-risk alcohol use, as a percentage of overall client population.
    4. The number of clients who are women of childbearing age who receive services for alcohol use management or a referral to a qualified substance abuse treatment professional, as a percentage of overall client population.
    5. A comparison of (1) the proportion of all clients experiencing a relapse during treatment, and (2) the proportion of all clients who are women of childbearing age and receiving alcohol-use management services that experience a relapse during treatment.

Addressing Relevant Regulations

Another aspect of assessing your agency is to determine whether implementing FASD prevention and/or intervention will conflict with the existing local and governmental regulations and standards that apply to your agency's operation.

For example, both the federal government and individual states have developed their own laws regarding the reporting of cases of known or suspected substance-exposed infants. These laws vary widely in their requirements, but are nonetheless of critical importance to any healthcare setting serving the needs of pregnant women. In addition, providing services to individuals who have or may have an FASD—a recognized disability—carries its own legal and ethical responsibilities.

The following sections discuss relevant regulatory issues related to (1) women who drink during pregnancy, and (2) individuals who have or may have an FASD.

Legal Issues Related to Women Who Drink During Pregnancy

Federal laws related to alcohol use during pregnancy tend focus on prevention and treatment of FASD rather than being punitive. State and local laws vary. Some states, such as Hawaii and Montana, have laws authorizing FASD prevention and treatment programs. Others, such as New Hampshire and Rhode Island, require that information on FASD be available to couples seeking marriage licenses. At least one state, Missouri, requires physicians to counsel pregnant patients about the dangers of alcohol use. It is important for counselors to stay abreast of state laws related to alcohol use during pregnancy and their effect on treatment and recovery.

The Administration for Children & Families, an agency within HHS, provides a searchable guide to state-level statutes regarding the reporting of substance-exposed infants (http://www.childwelfare.gov/systemwide/laws_policies/state/).

Custody Issues

Several states (e.g., Florida, South Carolina) do take punitive measures toward alcohol use during pregnancy, such as including prenatal alcohol exposure in their definitions of abuse or neglect. Such measures can be used to remove the child from the parent's custody. Texas allows involuntary termination of parental rights if a woman causes her child to be born addicted to alcohol (other than via a controlled substance legally obtained by the mother by prescription; Section 161.001[1-R]). Generally, a mother who abuses substances may be charged with child neglect or abuse. As a result, her children may be taken from her.

In Virginia, physicians, nurses, teachers, and other professionals are required to report certain injuries to children. For purposes of the law, “reason to suspect that a child is abused or neglected” includes a diagnosis by an attending physician within 7 days of a child's birth that the child has fetal alcohol syndrome attributable to in utero exposure to alcohol (Section 63.2-1509). One state, South Dakota, permits involuntary commitment of a pregnant woman who is drinking.

A number of experts fear that such punitive measures may discourage pregnant women with alcohol problems from seeking treatment. Many states take a more supportive approach:

These three states give pregnant women priority for alcohol treatment slots or otherwise provide access to treatment. Others (e.g., California) provide outreach or case management to pregnant women with substance abuse problems. California also may cover residential treatment for pregnant women under Medi-Cal. In addition, Iowa prohibits discrimination against pregnant women seeking alcohol treatment (http://www.legis.state.ia.us/IACODE/2001SUPPLEMENT/125/32A.html).

State and federal governments have established various policies in response to the risks associated with drinking during pregnancy. Among these are various arrangements to increase access to substance abuse treatment by pregnant and postpartum women. Such arrangements include state-run treatment services, funding for private providers, and mandates that such women receive a priority for available treatment. The Alcohol Policy Information System (APIS) addresses statutes and regulations mandating priority access to substance abuse treatment for pregnant and postpartum women who abuse alcohol. In addition, the SAMHSA FASD Center for Excellence Web site provides an FASD legislation report that is updated twice a year.

State statutes that remove custody from birth mothers of children with an FASD are designed to protect the children. However, the threat of losing custody can interfere with the woman's recovery, or cause her to leave prenatal care and/or treatment. The goal is to remain alcohol-free long-term and acquire parenting skills needed to retain child custody and have a healthy, intact family. When screening or referring pregnant women for substance abuse treatment, counselors will need to be familiar with the laws in his or her state and their impact on efforts at family reunification and client recovery.

Child Abuse Prevention and Treatment Act (CAPTA)

One of the most significant pieces of legislation impacting the provision of services to pregnant women is the Child Abuse Prevention and Treatment Act, or CAPTA (P.L. 93-247). Most recently reauthorized on December 20, 2010 (S 3817), CAPTA is designed to protect rather than punish women who give birth to substance-exposed infants. The intent of these reporting laws is that “The newborn and their families will be brought to the attention of the child protective agency in the community, and they will ideally receive needed services within their community” (Burke, 2007).

A new CAPTA state grant eligibility requirement modifies earlier CAPTA language that mandates identifying and making appropriate referrals by healthcare providers to child protective services—and developing service ‘plans for safe care’ of the child—of newborns affected by prenatal drug exposure. Added as a new category of ‘referral’ and ‘safe care plan’ requirement are newborns diagnosed with an FASD. This CAPTA amendment was not meant to cover all situations where a newborn's mother drinks alcohol during her pregnancy, but rather those where a newborn has facial characteristics, growth restriction, or other abnormalities (birth defects) caused by prenatal alcohol use.

This new CAPTA provision (and the earlier requirement regarding drug-exposed newborns) is not intended to have states make prenatal alcohol or drug exposure a category of child abuse or neglect or to make those children subjects of mandatory reporting laws. Congress carefully chose the word “referral” to avoid that. Rather, the goal is to address the safety and well-being of these children. Intervening early through safety plans that promote the health and well-being of these children will be key.

The U.S. Department of Health and Human Services (HHS) provides a comprehensive guide to the CAPTA legislation and its impact on service provision, as well as its implications for community-based family resource and supports grants (http://www.childwelfare.gov/systemwide/laws_policies/federal/index.cfm?event=federalLegislation.viewLegis&id=142). CAPTA is also discussed in Part 3 of this TIP, the online literature review.

Territorial and Tribal Laws

At this time, no U.S. Territories have laws related to alcohol use during pregnancy. Tribal laws vary, but the Indian Child Welfare Act (http://www.nicwa.org/policy/law/icwa/ICWA.pdf) requires the Indian Health Service (IHS) to make residential treatment available for pregnant women with alcohol problems. In addition, the definition of ‘health promotion’ in the Act includes FASD prevention. The Act also allows the IHS to make grants to tribes and tribal organizations for various FASD prevention efforts, including alcohol treatment for high-risk women. It also has provisions related to educating Native women about FASD.

Counselors working with Tribal populations will also want to consider the implications of the Tribal Law and Order Act (TLOA) of 2010 and the Indian Health Care Improvement Act (IHCIA), which was made permanent in 2010. Both seek to strengthen access to care and protection of personal rights among Tribal populations, particularly women.

Information about the TLOA can be accessed at http://www.narf.org/nill/resources/tloa.html.

Information about the IHCIA can be accessed at http://www.ihs.gov/ihcia/.

Confidentiality Issues

Laws such as the Health Insurance Portability and Accountability Act (HIPAA) may affect activities such as reporting of alcohol use during pregnancy. HIPAA has certain requirements regarding privacy and sharing of client information and records. Confidentiality laws vary by state and may affect the addiction professional's ability to share information with various social, health, and legal systems, such as child welfare agencies.

It is essential to be familiar with confidentiality laws in one's state and to consult with an attorney if necessary. Inappropriate reporting of current or previous alcohol use during pregnancy can jeopardize long-term recovery and can harm a counselor's career.

Legal Issues Related to Individuals with an FASD

The most prominent regulatory issue related to individuals who have or may have an FASD is to recognize their rights as individuals with (or potentially having) a recognized disability.

Americans with Disabilities Act Compliance in Treatment Plans

The Americans with Disabilities Act (ADA) of 1990 is a federal law that prohibits discrimination on the basis of disability in employment, state and local government, public accommodations, commercial facilities, transportation, and telecommunications. An individual with a disability is defined by the ADA as a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment. Treatment facilities cannot discriminate on the basis of a disability. Many individuals with an FASD will have cognitive disabilities that meet the definitions set forth by the ADA; in any case, such individuals should receive treatment that recognizes their condition as a disability that should not be discriminated against.

Counselors will need to incorporate accommodations for persons with an FASD into any treatment plans. For example, lighting at meetings may need to be dimmed to keep the person with an FASD from becoming over-stimulated. Reading materials may need to be adapted to a lower literacy level to accommodate cognitive deficits. More information on accommodating disabilities can be found in Appendix D of TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT, 1998; http://www.ncbi.nlm.nih.gov/books/NBK64881/). Part 1, Chapter 2 of this TIP discusses accommodations specific to individuals who have or may have an FASD.

More information on the ADA can be found at http://www.ada.gov/. For technical assistance related to ADA requirements, visit http://www.ada.gov/taprog.htm or contact SAMHSA's FASD Center for Excellence toll-free at 1-866-STOPFAS or by visiting www.fasdcenter.samhsa.gov.

Addressing Staff Competence

Where Is the Clinical Expertise in Your Agency?

Change in clinical practice is best facilitated by assessing the skills of well-trained and experienced clinicians and targeting them for training and/or enlisting them in helping less skilled counselors facilitate change. Two clinical management structures are described here—interdisciplinary teams and traditional clinical supervisors.

Interdisciplinary teams are one effective way to ensure that the expertise for providing FASD-informed treatment is available in your agency (Clarren & Astley, 1997; Clarren et al., 2000). If you have interdisciplinary teams in your program, the teams assume the responsibility of tailoring interventions to an individual client's needs in a way that addresses FASD seamlessly. Such teams provide ongoing support, education, and treatment planning assistance for all staff. Teamwork creates an enriched environment for implementing FASD-informed techniques.

If your agency has an interdisciplinary team format for responding to other issues, this may be adapted to FASD. With an interdisciplinary team, you have an advanced level of capability for addressing FASD prevention or intervention in clients with substance use or mental disorders. This assumes that the more experienced and skilled members of the team have the knowledge, skills, and attitudes required to apply FASD-informed interventions and to supervise and coach application of an intervention for other counselors.

Many treatment agencies do not have interdisciplinary teams and instead rely on the expertise of clinical supervisors to evaluate and support the work of line staff. Clinical supervisors must have the knowledge, skills, and abilities required to apply an intervention and be able to demonstrate the intervention before they can coach others to perform it. The supervisors must also have the time to supervise and coach the staff. If this describes the supervisors in the setting where you work, you have an intermediate capability to provide FASD-informed care. If the supervisors have not yet reached this level, then you have a beginning capability for implementing FASD-informed care and must develop a plan to build the resources necessary to increase capacity.

The Frontline Staff and Clinical Supervisors

Once you've assessed the agency, you may want to assess the staff who will actually implement the change (see How-To 2.6).

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How-To 2.6

How to Assess the Frontline Staff and Clinical Supervisors for Change (Figure 2.1, Step H). The committee determines the specific program and staff members who will be the first to implement change. Are there incentives/organizational supports for change (more...)

Staff Qualifications and Competencies

As a part of implementing FASD-informed services, a number of process-oriented tasks should be completed, including an assessment of initial staff competence, education and training, development of skills and resources, and supervision. These considerations are relevant not only to the counselors' ability to deliver the services but also to clinical supervisors, other clinical staff, and support staff responsible for recording and billing services.

Compared with those providing support services, however, the required level of knowledge and skill is significantly different for those directly involved in clinical care. For this reason, the attitudes, knowledge, and skills required to provide FASD-informed services are separated into four categories:

  1. Administrative and support staff
  2. All clinical staff
  3. Counselors designated to provide FASD-informed services
  4. Clinical supervisors overseeing the counselors who provide these services

The four checklists that follow serve two purposes. First, they can be used to assess staff and organizational readiness to implement or sustain FASD-informed services. Second, they can be used to identify gaps in training and supervision to be addressed with individuals or groups.

Addressing Gaps in Staff Capacity to Deliver Services

Not all clinical staff are ready, willing, or able to address co-occurring issues such as FASD. The clinical supervisor is charged with helping staff and administration differentiate the level of new knowledge, attitudes, and skills needed to help counselors and support staff address co-occurring substance use/mental health disorders and FASD prevention and intervention. The characteristics and competencies checklists presented above outline the qualifications needed at various levels or in agencies wishing to provide FASD-informed services in clients with substance use or mental disorders. However, gaps may exist; staff may be lacking in various areas and require additional training and support. In this instance, the implementation workgroup described in earlier sections may be commissioned to identify these gaps and to develop plans to provide specific training and support to individual staff members on an as-needed basis.

In addition to developing individualized plans to develop attitudes, skills, and knowledge, a number of organizational approaches can be used both to reinforce the change and to overcome resistance to change. The Change Book (ATTC, Second Edition 2010) offers valuable suggestions on addressing resistance to change (particularly pp. 27–28). These include such strategies as openly discussing staff feelings related to the change, celebrating victories, promoting feedback about the change as a vehicle to improve the process, being realistic about goals, identifying and using the change leaders in promoting the change, and providing training related to the change.

Approaches to Staff Training

It is recommended that training aimed at developing the basic attitudes, knowledge, and skills for delivering FASD-informed care be provided to all agency staff as part of implementation. It is important for clinical staff to see the link between the change and organizational leadership. Thus, administrators need to attend these sessions to personally provide the vision of the organization. In addition to training current staff, it is important to consider the ways in which the organization can communicate the vision to new staff. This may be most efficiently accomplished by using existing vehicles, such as new staff orientation and training sessions and worksite orientation procedures.

Training of all clinical staff members on attitudes, knowledge, and skills specific to their positions can be conducted by administrative or clinical supervisors. Again, it is important to communicate the commitment of leadership to integrating FASD-informed services. In addition, it is recommended that training sessions provide practice in the skill areas outlined in Checklist 3. To reinforce the importance of the need to provide FASD-informed services, clinical and administrative supervisors are advised to incorporate didactic education, identification of incompatible attitudes, and coaching on the skills needed to implement the policies within existing supervision sessions and team meetings. In short, the agency's vision and commitment to addressing FASD must inform all clinical interactions between supervisors and counselors.

Checklist 3. Characteristics and Competencies of All Clinical Staff.

Checklist 3

Characteristics and Competencies of All Clinical Staff.

Figure 2.2 provides a list of recommended credentials for trainers; Appendix C, Public and Professional Resources on FASD, lists resources for FASD prevention and intervention training. How-To's 2.7 and 2.8 discuss the process of selecting a trainer, and how to continue the learning after the initial training is completed.

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Figure 2.2

Recommended Credentials for Individuals Providing Training in FASD. Advanced education in counseling, social work, or psychology. Minimum of 5 years' experience delivering substance abuse and/or mental health treatment. Being a qualified/experienced (more...)

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How-To 2.7

How to Select a Trainer. Qualifications to look for in a trainer include the following: Experience working with the clientele being served.

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How-To 2.8

How to Continue the Learning After the Initial Training is Completed. Assess the staff's knowledge, abilities, and skills with the core components of the techniques. Check to see that staff continue to reframe the issues of individuals with FASD as being (more...)

Addressing Community Relationships

How Do You Develop Referral Relationships?

Access to a range of other health and social resources is essential to quality care in substance abuse and mental health treatment settings, particularly for clients who have or may have an FASD. Agencies to which staff might refer can be screened using the following variables:

  • Willing to accept referral of clients who have or may have an FASD.
  • Sensitive to substance use or mental health issues.
  • Able and willing to work with agencies such as ours, including regular review/discussion of any collaborative issues.
  • No or low funding impediments to working collaboratively.
  • Good professional reputation in the community.
  • Sufficient funding to address the needs of clients we are referring.
  • Willing to cross-train with our staff.
  • Existing personal relationship with the referral agency.

Also, it is preferable if certain FASD capabilities are present in any agency to which you refer:

  • Individualized service planning.
  • Acceptance of disability.
  • Recognition of strengths.
  • Incorporating individual behaviors.
  • More active involvement (transportation, personally ensuring client ‘hand-off,’ follow up, etc.).
  • Services available to child and Mom (when the FASD is intergenerational).
  • Flexibility in programming (modifications will be necessary; are they willing to make them?).

How Do You Develop Relationships With the 12-Step Community?

It is useful to have the program's policy and procedures manual reflect an understanding of the essential role that 12-Step programs play in the treatment of clients with substance abuse complicated by FASD. Mental health personnel need to be sensitive and competent in integrating the principles and practices of self-help programs into the clinical process. This requires knowledge of the underlying philosophy of the 12-Step model, and an understanding of how the programs function and are structured. In like manner, counselors practicing from a 12-Step facilitation model need to appreciate how principles and practices are linked to sound counseling.

For example, the use of slogans as a form of cognitive restructuring and debate is helpful to most clients. The use of structured practices like daily meetings, sponsor contact, and reading self-help group literature can help create alternate forms of reward, relief, and life-management. The policy should recognize barriers to individuals with an FASD accessing and using 12-Step programs, including:

  • Whether the individual being referred requires a navigator to help them find meetings, attend them regularly and on-time, and participate appropriately;
  • Insufficient social communication and social awareness skills on the part of the individual being referred; and
  • Potential exploitation of the individual by other members of the group.

How Do You Find and Use Behavioral Health Resources in the Community?

Most substance abuse and mental health programs can benefit from consulting relationships with physicians, psychologists, social workers, and other community medical, rehabilitation, social service, and mental health providers who have specialized knowledge and resources in addressing the needs of clients who have or may have an FASD. As indicated in Part 1, Chapter 2 in the table titled In-House FASD Assessment: An Ideal Core Team, important professional areas to focus on in building relationships include neuropsychology and speech language pathology, occupational therapy, physical therapy, and a primary care physician.

These professionals can provide adjunct resources for such issues as difficult assessments and differential diagnosis, placement in appropriate treatment programs and/or support groups, medical management of co-occurring chronic medical conditions, specialized psychopharmacological services for clients with an FASD, discharge planning, and family services.

Finding and using these resources may be different from finding and using referral resources. Understanding the services that can be provided, fees for service, whether the service can be provided in the treatment program or whether the client must travel to a remote site, and the processes for reporting results of evaluations are some of the issues that need to be considered in using community resources. Generally, unlike referral resources, community resources will not have a formalized contract or agreement with the treatment program. Therefore, issues of confidentiality and information reporting will need to be explored.

Addressing Financial Considerations

Billing

Integration of FASD-informed services is intended to enhance treatment outcomes and, because these services are delivered by licensed and/or certified counselors who are modifying or offering tailored treatment, rather than changing the focus of treatment, such services are likely to be reimbursable under the client's primary treatment diagnosis. In this case, individual sessions that incorporate accommodations for FASD may be billed as individual counseling, psychotherapy (interactive or regular), or family therapy associated with the primary diagnosis. Organizations are advised to clarify this with state, county, federal, and private funding sources and to identify the specific procedures required to facilitate billing. Financial considerations also reinforce the need for support staff responsible for billing to understand how these services are delivered and their relationship to the primary diagnosis.

For organizations reimbursed based on case or capitated rates, reimbursement is not likely to change. Services that incorporate FASD are likely to be viewed by managed care organizations or funding agencies as value-added or optional services and thus included in established rates of reimbursement. Although incorporating FASD-informed services is not likely to increase reimbursement rates, it may improve performance on contractually mandated outcomes such as treatment engagement, retention, and effectiveness.

In their document Operational Standards for Mental Health, Intellectual/Developmental Disabilities, and Substance Abuse Community Services Providers (2011), the state of Mississippi has developed operational standards that can help define and inform a state reimbursement system. They are reprinted in full in Appendix H, Operational Standards for Fetal Alcohol Spectrum Disorders (FASD): A Model. In addition, Part 3 of this TIP, the online literature review (http://store.samhsa.gov/home), contains a discussion of reimbursement codes related to FASD, as well as the implications of the Patient Protection and Affordable Care Act.

Sources of Funding

Most of the costs of implementing FASD-informed services occur early in the process of implementation, so local foundations are potential sources of funding. A one-time cost of training and knowledge dissemination to staff offers a discrete, relatively low-cost, and an attractive opportunity for local foundations to contribute to improving treatment outcomes. Applying collaboratively with other agencies demonstrates established partnerships, and should be pursued where possible. The Council on Foundations (www.cof.org) is an excellent starting point for identifying foundations near you and researching their missions. Other potential sources of funding include traditional state and federal grants and contracts, direct charges for services from third-party payors, and client fees for service.

Additionally, if the services provided are innovative (addressing FASD is an emerging area of care), agencies should consider partnering with social and psychological researchers at a local university to obtain research funds to support clinical efforts. Such research efforts can have many beneficial secondary effects for agency status in the community, such as developing alternative sources of funding, partnering with new groups interested in substance abuse or mental health issues in the community and/or creating learning communities, as well as providing funds for the identified project.

Addressing Continuity and Fidelity

For FASD-informed services to be fully adopted, the importance of these services will need to be consistently communicated. Policies, mission statements, program descriptions, clinical and administrative training, team meetings, and clinical supervision sessions are all useful avenues for communicating the organization's commitment to delivering FASD-informed care (see Figure 2.3). If not formally revised, these policies should at least be reviewed to ensure that they are broad enough to encompass FASD-informed services.

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Figure 2.3

Avenues for Communicating Organizational Commitment to Delivering Services to Address FASD. Mission and vision statements Strategic plans Annual goals Program descriptions Treatment philosophy statements Policies and procedures Training sessions Team (more...)

Implementing the Intervention With Fidelity

When implementing any intervention, it is important to identify the active elements that characterize that specific intervention. Ensuring that a new intervention is being implemented with fidelity, as distinguished from standard practice, allows administrators to more easily determine whether the new intervention is responsible for changes in expected outcomes.

For FASD-informed care, fidelity can present challenges. Behavioral health fields are encouraged by federal agencies and funding organizations to use evidence-based approaches that have not been developed for, or accommodated to, FASD. Evidence-based approaches specifically tailored for FASD are, for now, limited, though some that have been developed and tested do have built-in fidelity monitoring mechanisms.

Fortunately, the FASD evidence base is growing rapidly. There are several scientifically validated interventions now available. There is also expert clinical consensus and publications using systematic research review and synthesis that provide support for the interventions recommended in this TIP (e.g., Adubato & Cohen, 2011).

There is also precedent for tailoring interventions. For example, the past decade has brought methods for inclusion of trauma and other co-occurring disorders into treatment provision and planning into mental health and substance abuse treatment. This could be considered ‘trauma-informed’ care. Established practice (e.g., cognitive behavioral therapy, or CBT) has been altered and improved by informing standard care with methods to respond to these issues (e.g., trauma-focused CBT). The strategies that have been used to modify or transform practice with these issues in mind can be used by agencies to create FASD-informed care while still maintaining fidelity of existing practices.

To create FASD-informed care and demonstrate fidelity, agencies are encouraged to:

  • Access reliable FASD prevention and intervention training (training resources provided in Appendix C).
  • Use this TIP and/or other manualized approaches for FASD-informed care. Suggested resources for other manualized approaches include:
    –

    The SAMHSA FASD Center for Excellence (primarily FASD intervention)

    –

    The CDC (FASD prevention and intervention approaches)

    –

    (http://www​.cdc.gov/ncbddd/fasd/training​.html)

  • Use checklists provided in this Implementation Guide to conduct process and outcome measurement.
    –

    If available, use fidelity checklists for other manualized approaches for FASD-informed care (be sure that fidelity checklists describe the active elements of an intervention and define them in behavioral terms).

  • Where possible, and if not cost-prohibitive, bolster use of checklist(s) with direct observation of new clinical activities.

Some issues to be solved when implementing intervention fidelity monitoring:

  • Which staff members measure specific parts of the checklist(s)?
  • How are results conveyed to staff?
  • How does a program define an acceptable fidelity score?
  • How are positive results of the efforts measured by the checklist rewarded?
  • What actions need to be taken if there is poor fidelity to program elements and goals?
  • How are elements of checklist(s) updated over time, and when program changes occur?

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