HISTORY AND PHILOSOPHY

Located in Baraboo, St. Clare Center Bio-Behavioral Health Services began at St. Clare Hospital and Health Services in 1986. The major components of our model for the treatment of substance addiction have developed incrementally over the intervening 13 years into a comprehensive system of modalities, techniques, and literally, location of service. St. Clare Center's primary service area in southwestern Wisconsin encompasses approximately 7,500 square miles, with a population density average of less than fifty people per square mile.

St. Clare Center addresses substance addiction as a biological phenomenon -- a disease -- that is strongly influenced by psychological, social, and more often than not, hereditary factors. Our role is to utilize the best-established research on addiction and recovery to assist patients in developing the motivation, knowledge, and skills, to accept and address these "bio-psycho-social" factors in their lives and in developing an individualized plan for their ongoing self care and support.

EFFECTIVE TECHNIQUES FOR RECOVERY

AODA treatment has been, until recently, a paraprofessional field primarily due to a lack of research and outcome data. Services largely consisted of 12-step programming and a variety of personal techniques that individuals and programs "hoped would work." While the enormous body of anecdotal and now empirical information suggests that 12-step facilitation is highly effective, outcome research has not supported many "sacred cows" of the past. For example, self-esteem building has been shown to have little effect in prevention or treatment and a few studies suggest that students completing programs that focus solely on building self-esteem are slightly more likely to use drugs.

It has been the goal of St. Clare Center to provide professional healthcare services for addictions -- "care pathways" that are based on well-replicated outcome data and best practices, like any other area of healthcare. St. Clare Center's system programming is designed around four key elements demonstrated to be effective in addictions treatment:

1. Motivational Enhancement which blends two primary techniques:
• Motivational interviewing strategies seek to "meet the patient where they are" and progressively build on existing and emergent strengths -- we view motivating the patient to recovery as our responsibility.
• St. Clare Center marries a variety of cognitive-behavioral strategies, including Rational-Emotive Behavioral Therapy, "corrective thinking" protocols, and 12-step philosophy. This education and experiential model facilitates patients making changes in their belief, thought, and coping systems. The goal is positive change in behavior and, yes, self-esteem.
2. Relapse Prevention -- Didactic and experiential relapse prevention strategies, adapted from the CENAPS (an acronym for Center for Applied Behavioral Sciences) and other models, result in patients developing a "continuing care plan." This is a work in progress strategy that follows patients throughout their treatment and recovery experience with short and long term goals and strategies for relapse prevention and self-care based on current and emergent insights and needs.
3. Biogenetic Recovery -- The latest research on what addiction is. Utilized in creating a construct for patients to view their illness as a bio-psycho-social health issue in which treatment provides the prescription for recovery. This view of addiction also results in St. Clare Center's promotion of physical health -- diet, exercise, etc. -- as intrinsic to recovery. Our ongoing assessment process also recognizes that a predisposition to addiction is only one of several obsessive/compulsive type disorders that often occur in the same family, frequently appear simultaneously in the same patient and often appear in recovering patients as cross-addictions or secondary diagnoses. Logically, this model calls for intervention and assessment in our work with families as well, and both patients and their family members frequently leave primary care with "continuing care plans" calling for evaluation and treatment of related biogenetic issues.
4. 12-step Facilitation -- The cognitive-behavioral and spiritual techniques developed by Alcoholics Anonymous continue to be the only "program" for long term support in recovery with a positive track record, hence, AA/NA participation is mandatory for St. Clare Center patients. Various lectures and experiential programming motivate patients to participate, demystifies the meeting process, and facilitates their internalization of the basic concepts of surrender, spirituality, personal inventory, etc.

MENU OF SERVICES

The St. Clare Center Model provides all four Wisconsin Uniform Placement Criteria (WI-UPC) levels for substance abuse services, and facilitates an individual patient's entering of treatment at the level appropriate to their needs and moving to a less-restrictive level of care as quickly at the patient's recovery goals are met. These levels of care include:

• Level 4 Detoxification Services are medically managed and available on the medical/surgical floors at St. Clare Hospital.

• Level 3 Residential Treatment is provided on the St. Clare Center unit of the hospital. This is a medically supervised inpatient-type setting allowing for limited medial evaluation and 24-hour a day care in a controlled environment. Services are provided seven days a week with special focus on intensive diagnostic and therapeutic work and family issues on Sunday and Wednesday. Staffing includes:
• Supervision by a physician who is a certified addictionologist.
• A daytime registered nurse providing nursing services; "off-hour" medication, nursing, and emergency services are provided by other hospital units.
• Three certified alcohol/drug counselors and at least on intern providing case management, and counseling in staggered shifts so that at least two are on duty at any given time.
• Family services and further diagnostic work facilitated by a masters-level psychotherapist.
• An intake specialist providing alcohol/drug evaluations and admissions services, often in concert with nursing, referring patients to the appropriate level of care.
• A Ph.D. psychologist who attends regular patient staffings and provides psychometric testing and further diagnostic services.
• 24 hour coverage by specially trained patient care assistants.
• Supervision of admissions, treatment planning, and program facilitation by the clinical supervisor for addiction services.

This staffing pattern and the location within a well-equipped community general hospital allows Level 3 service to provide a high level of care and availability of medical and other services including those for handicapped patients, the elderly, and individuals with medical problems needing ongoing monitoring.

• Level 2 Day Treatment Services and the "hotel stay" option. Day treatment service is "piggy-backed" on the residential program and offered seven days per week. Features include:
• Case management by a certified alcohol/drug counselor and case staffing by the multi-disciplinary team as described earlier.
• Morning and afternoon "blocks" of educational, group, and individual primary treatment services. Patients are scheduled for between four and fourteen "blocks" according to the individual treatment, family, work, child care, and other needs. For example, one patient may be treated all day Saturday and Sunday, then come in only in the morning on certain weekdays.
• Some patients may require only Level 2 Day Treatment Services, but live a prohibitive distance from the primary treatment site in Baraboo. The "hotel stay" option allows these patients to purchase room and board at St. Clare Hospital for a nominal fee, receive services of the appropriate intensity at the hospital, and attend sessions on intervening days at their local clinic.

• Level 1 Outpatient Clinics are located in New Lisbon, Lancaster, Richland Center, and Baraboo (a separate site from the hospital.) Aftercare, psychotherapy, and primary substance abuse/addiction services are available for patients less impaired by bio-psycho-social issues at these clinics. Each clinic provides:
• Abuse/addiction services by a certified alcohol/drug counselor, supervised by the clinical supervisor.
• Mental health evaluation and psychotherapy by a master-level therapist, under the supervision of a psychiatrist (the Richland Center Clinic has an on-site psychiatrist.)
• Outreach, primary prevention, and other services. Each clinic provides slightly different programming based on the needs of the communities they serve.
• Immediate access to and coordination of services with the primary treatment services in Baraboo. Each clinic acts as a local "feeder" to higher levels of care, while providing convenient, local transitional services in the patient's home area.

Intrinsic to the St. Clare Center Model is its flexibility in matching patients with the level of care appropriate to their individual needs. Patients have the ability to move to a less or more intensive level of care or regimen of services within a particular level of care as they progress in treatment or issues emerge. This is facilitated by ongoing patient assessment throughout the system, and results in patients receiving only the level of services that they require -- and the maximization of their health care benefits.

For purposes of illustration, the following is more or less "typical" experience of an addictions patient through the menu of services at St. Clare Center.

July 12th:

Evaluated by alcohol/drug counselor at New Lisbon clinic. Evaluation suggests need for Level 4 detoxification. Patient referred to St. Clare Hospital, Baraboo, the same day. Evaluated by nursing staff and intake specialist who concur. Admitted to Level 4 detoxification on 3 West Med/Surg unit.

July 15th:

Patient assessed as medically stable, but in need of 24 hour monitoring due to relapse risk and unstable home situation. Transferred to Level 3 Residential Treatment.

July 21st:

Relapse risk assessed as reduced, home situation stabilized somewhat following Family Day activities (family referred to psychotherapy at New Lisbon clinic). 24 hour monitoring no longer necessary but patient continues to need primary care. Transferred to Level 2 Day Treatment to attend morning sessions on weekdays and all day Saturday and Sunday. Review regimen as goals are met.

August 2nd:

Significant progress noted in meeting goals and developing a sober support system; has secured a 12 step sponsor in New Lisbon. Patient will continue in Day Treatment, attending Saturday and Sunday all day on August 7-8 and 14-15, and also individual sessions on intervening Wednesdays.

August 15th:

Patient assessed as having met Day Treatment goals, relapse potential significantly reduced. Possible symptoms of adult Attention Deficit Disorder have been noted by the family therapist; and, recommendation for evaluation is noted on the continuing care plan. Patient is discharged from Day Treatment, and referred to aftercare services at the New Lisbon clinic.

August 18th:

Patient begins weekly aftercare group, individual counseling sessions are held monthly and as necessary. Continues with 12-step groups. Family continues with psychotherapy; conjoint sessions as necessary.

October 6th:

Patient is evaluated for Attention Deficit Disorder by New Lisbon psychotherapist, begins treatment for the same.

December 2nd:

Discharged from addictions services.

Where hope begins and abuse ends.

MISSION

The mission of the Milwaukee Women's Center (MWC) is to research, develop and administer programs to end abuse. For nearly twenty years, MWC has provided high-quality research, prevention, intervention and support services in the areas of family violence, homelessness, alcohol and drug abuse, mental health, poverty, and maternal child health problems. MWC celebrates diversity, fosters creativity and helps strengthen families to end abuse.

HISTORY

Based in Milwaukee, Wisconsin, the Milwaukee Women's Center, Inc. was founded in 1980 as a private, non-profit, women and minority governed organization. The first program initiated by the agency was an emergency shelter for women and children who were victims of family violence. As more women and children entered shelter, it became apparent over time that these women and their families were in need of services that extended beyond just temporary shelter. These needs included victim support groups, substance abuse and mental health counseling/treatment, parenting classes, and children's programming.

In 1987, MWC developed and implemented integrated services for women and children affected by violent relationships, substance abuse, and mental health issues. After screening for short- and long-term treatment needs, outcomes indicated that 40% of women in MWC's shelter entered with substance abuse issues. Today, the shelter provides support groups and comprehensive programming for substance abuse and family violence issues. Additional programs for children in shelter are also provided and are designed to educate them about self-protective behavior, healthy lifestyle choices, and resources available in the community.

In 1989, the Wisconsin Act 122s.46.48(19), titled "Multi-disciplinary Prevention and Treatment Team for Cocaine Families" provided $1,050,000 for a "multi-disciplinary prevention and treatment team in Milwaukee County for cocaine abusing women and their children." MWC was awarded this grant and initiated POWER (Positive Options for Women Entering Recovery) in 1990.

POWER -- (Positive Options for Women Entering Recovery)

POWER is an integrated service delivery system designed to meet and treat the specific needs of culturally diverse women. The program was created in response to the lack of services that integrated alcohol and drug abuse, domestic violence, and mental health programming while utilizing a women-sensitive and race-sensitive treatment approach.

TARGET POPULATION

The primary population of consumers are single mothers and pregnant women, between the ages of 18 and 55, and their families living in poverty who have a current or recent history of family/intimate violence, cocaine abuse and/or other drug or alcohol addiction and/or mental health issues. In 1998, approximately 70% of consumers were African-American, 20% Caucasian, 5% were Hispanic/Latino and 5% the ethnic heritage was unknown. Each woman served had an average of 3 children. The non-custodial parent of the women's children is usually engaged in the treatment process and offered services in case management, treatment, parenting and/or abuser treatment.

HOME AND COMMUNITY BASED CASE MANAGEMENT AND TREATMENT MODEL

The POWER program is a multi-disciplinary, case management and integrated substance abuse and mental health treatment model. POWER is a non-institutionalized model of service delivery that operates in the homes, neighborhoods and communities of consumers. Through short- and long-term case management and treatment, the program addresses the barriers that prevent women from succeeding in traditional alcohol and other drug abuse (AODA) treatment programs.

METHODS OF POWER INCLUDE:

A multi-disciplinary focus:

• Access to expert professionals in medical, social services, childcare, and substance abuse fields.
• Establishing relationships with managed care and HMO providers.

• Case managers establish relationships with other key professionals in external systems where women are involved (e.g. welfare reform and child welfare agencies, probation and parole, and medical practitioners).

• Continuum of care for each client/family that includes comprehensive wrap-around services located at the Milwaukee Women's Center, Inc. and with MWC's preferred providers and collaborators.

Home- and community-based case management services

• Access to alliances and support networks within the community to help foster goal attainment.
• Use of home-based services to women and children in their own environment.
• Access to community resources including emergency food, clothing, housing, and energy assistance.
• Focus on prenatal care, infant care, and parenting skills.

Client-centered care

• Developing individualized treatment plans around the participant's individual needs and circumstances.
• Using a consumer advocacy approach that encourages each client to set her own goals and build on her strengths.
• Working with the family of each client to build the client's kinship network which can be a key resource for her recovery.

GOAL OF POWER

To provide comprehensive and integrated case management and treatment services to women and families that promotes healthy individual lifestyles and builds strong, productive families.

OBJECTIVES OF POWER

1. To provide home and community based case management services to promote healthy women/mothers who are better able to care for their own health and that of their born and/or unborn children.
2. To maintain and increase the level of broad-based community support and collaboration to enhance client success through appropriate and accessible resources.
3. To recruit, maintain, train, and support a highly qualified and diverse workforce.
4. To work closely with MWC's child welfare subsidiary Innovative Family Partnerships, Inc. in integrating POWER services into child welfare treatment and permanency planning.
5. To integrate government, Medicaid, and private funding on behalf of POWER families.
6. To provide gender and culturally competent mental health, alcohol and drug abuse treatment.
7. To promote self-sufficiency and economic growth through employment and education.

POWER IN ACTION

A client example

Substance abuse creates a host of barriers and challenges to building healthy families, gaining and retaining employment, and moving towards economic self-sufficiency. A young mother of three entered the program in 1996 at age 23. She was pregnant, unemployed, homeless, very insecure and lacked support from family or friends. She struggled with issues of childhood abandonment and physical, mental, and emotional abuse. After fully engaging in the comprehensive case management program and building a strong relationship of support and trust with her case manager, she 1) located independent housing, 2) was able to meet all court requirements for reunification for her three children who had been in foster care for over a year, 3) gave birth to a drug-free baby, 4) stayed sober and free from relapse, 5) increased her self-esteem and enrolled in a GED program. She was discharged in 1998 and today lives with all her children, is employed full-time, and leads a productive and drug free life.

Community-based programming

MWC believes, as an agency as well as throughout all levels of case management, that it is essential to develop alliances and support networks within the community that help to foster the attainment of POWER's goals. MWC has a network that extends from shelter care for homeless clients to outpatient treatment (mental health and alcohol/drug abuse) to residential family services. Case managers have established and maintained alliances with many agencies to acquire access to this range of services including child care and transportation services. The following agencies provide training, education, and collaborative services to POWER program staff and their clients:

1. EFNEP (Extension Food and Nutrition Education Program) educates POWER clients on nutritional well being.
2. Planned Parenthood provides education and training on sexuality/parenting and planned pregnancies.
3. Wisconsin Department of Health and Family Services provides information on sexually transmitted diseases and communicable disease such as tuberculosis, and provides follow up with counselors on client participation.
4. Milwaukee Police Department donates furniture, clothing, and toys for POWER families.
5. Division of Probation and Parole provides follow up with counselors on client participation.
6. New Concepts/Foster Care Program provides follow-up with client participation.
7. La Causa offers satellite program foster care and crisis intervention day care.
8. Meta House offers residential AODA treatment for clients and families.
9. Crossroads offers residential treatment for single clients.
10. YWCA offers transitional residence for clients leaving emergency shelter.
11. Hope House offers shelter accommodations for homeless clients.
12. Hospitals such as Sinai Samaritan-Women's Assessment and Northwest General for AODA Services.
13. Community Advocates offer temporary transitional residence for clients.
14. UW-Extension provides educational programs for clients.
15. AIDS Resource Center of Wisconsin provides HIV/sex education for clients.

Internal wrap-around services

At the Milwaukee Women's Center, Inc., POWER clients have access to a comprehensive array of services to meet their individual needs. These services include:

• 24-hour emergency shelter and supportive services for women and their children who are victims of family violence,
• Mental health and AODA counseling services at the Behavioral Health Clinic, and,
• Home-based assessment and intervention services for developmentally delayed or disabled infants and toddlers through the Birth-to-Three program.

The program staff receives supervision and consultation with the agency's medical director and Behavior Health Clinic director. Team case management is conducted with appropriate staff members according to the needs of the POWER families.

Connection to external systems

The Director of POWER regularly meets with state and other local providers, W-2 sites, the Milwaukee Bureau of Child Welfare, and Probation and Parole. The meetings provide the opportunity for advocacy on behalf of POWER clients and the ability to further increase client access to services and treatment. In turn, representatives from larger systems can receive current information and feedback on the needs of these women and families.

In terms of cross-collaboration, W-2 agencies and other service providers in the community can receive the following services at MWC to assist their clients with substance abuse and family violence prevention:

• AODA and mental health screens,
• AODA counseling and mental health therapy,
• Case management services,
• Family counseling,
• Batterer's treatment, and
• Other support group services (i.e. parenting, domestic violence education, sexual education, family dynamics, etc.).

EVALUATION OF POWER

In 1992 the University of Wisconsin-Milwaukee, Center for Addiction and Behavioral Health Research was hired by the Milwaukee Women's Center, Inc. to evaluate the POWER model. Results indicated that case management services were essential with this population of women and children. Based upon the multiple diagnoses of depression, personality disorders, schizophrenia, paranoia and/or other problems among the all the women in POWER, that stemmed from abuse, neglect, sexual assault, and AODA problems, the evaluation results made a strong case that an integrated model of service delivery was necessary and successful for these women and children.

POWER continues to be evaluated in an ongoing manner through the use of client feedback surveys, managed information systems and quarterly program reports. The retention, length of sobriety, and positive outcomes of women and children in the program reflect the strength of the model. The computerized management information system provides information on services delivered, length of stay in program, and other program statistics that support program activity. The quantifiable data is then generated and monitored on a quarterly basis by program reports.

Each quarter, through staff evaluation and client feedback survey data, program strengths and weaknesses are identified in order to determine innovative solutions to address key problem areas. The Program Director is responsible for consultation with the President/CEO and implementation of program changes to alleviate problem areas.

In preparation for 2000, POWER will:

1. continue to refine the outcomes based performance measures,
2. receive any training and/or guidance offered by the Wisconsin Bureau of Substance Abuse Services regarding outcome measurements,
3. monitor client progress and outcomes related to foster care, employment, education, discharge status, and other effective methods for measuring quality of service delivery, and
4. collect additional follow-up data on client outcomes after discharge.