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May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 STATE SUBSTANCE ABUSE TREATMENT STANDARDS FOR WOMEN: A REVIEW OF THE CURRENT LANDSCAPE Prepared for Discussion at the NASADAD-WTC 2007 Annual Meeting June 6, 2007, Burlington, Vermont I. INTRODUCTION/OVERVIEW The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD) have entered into a collaborative venture to strengthen the State Women's Treatment Coordinators (WTC) network and develop guidance to States on creating substance abuse treatment standards for women. In 2005, Children and Family Futures (CFF), contractor to CSAT, did some initial work to learn about State standards. CFF informally surveyed the WTCs to find out which States had standards or protocols for women and/or pregnant women (beyond the SAPT Block Grant requirements) and prepared a summary of key themes from the standards for discussion at the WTC 2005 Annual Meeting. The WTCs found this preliminary discussion and information about the standards very helpful. The recent CSAT-NASADAD collaboration and 2007 WTC-NASADAD Annual Meeting set the stage for revisiting this issue to update the knowledge base about existing State women's treatment standards. In March 2007, a brief questionnaire was sent to all State WTCs; for the 5 States that did not have a designated WTC at the time, the questionnaire was sent to the State Director. The questionnaire sought information on whether the State had substance abuse treatment standards or protocols for women and/or pregnant women (beyond the SAPT Block Grant requirements); when such standards went into effect; whether they had ever been revised; and key issues areas that NASADAD should address in developing guidance to the States. CFF received responses from 49 States and the District of Columbia. A total of 28 States (55 percent) indicated they had some kind of standards for women and/or pregnant women beyond the SAPT Block Grant requirements; 20 States (39 percent) said they did not have standards; and 3 (6 percent) said they were developing standards. Copies of standards from the 28 States were collected and reviewed by CFF.1 Attachment 1 provides a State-by-State list of these results and identifies the materials reviewed for the 28 States. CFF's review entailed a qualitative content analysis of the State standards, using the CSAT Comprehensive Substance Abuse Treatment Model for Women and Their Children as an organizing framework. The CSAT Comprehensive Model recommends that treatment providers provide a range of clinical treatment and support services to women and to children, as well as community support services to families, that cut across the continuum of care. In addition, CFF also looked at the standards for other more general administrative issues such as staffing, and outcomes and monitoring. This document presents the key themes regarding comprehensive 1 The 28 States/jurisdictions reviewed were: Arizona, Arkansas, California, Colorado, Connecticut, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Maine, Massachusetts, Missouri, New Hampshire, New Jersey, Nevada, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Washington, Wisconsin and Wyoming. Though Wyoming did not complete and submit the questionnaire, standards relating to women were obtained and reviewed from an Internet search. The three States that indicated they are developing standards are Alabama, Louisiana and Maryland. In addition, New Jersey, which has standards for women, indicated it is also in the process of developing standards for pregnant women. 1 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 services and select administrative issues, as well as a brief discussion of the issues WTCs said they would like NASADAD to address in developing guidance to the States. In considering the information that follows, it is important to note that we only reviewed treatment standards specific to women; we did not review general treatment standards applicable to all providers, which also likely speak to some of the areas identified below. For instance, State standards may affirm that programs serving women need to meet women-specific standards in addition to the general and modality specific standards required for all substance abuse treatment programs. II. HIGHLIGHTS OF THE REVIEW The results of the review are organized into 13 areas below that include overall findings, as well as specifics related to services and service delivery issues. 1. Lack of Uniformity in State "Standards" Unlike many other health care issues, there is no "standard" that exists to ensure that individuals receive high quality, evidence-based substance abuse treatment services. Instead, the substance abuse treatment system is governed by a patchwork of mandated State policies.2 Indeed, this review indicated that, overall, treatment standards for women and pregnant women vary greatly across the States. There is a substantial degree of variability when it comes to breadth, depth, scope and emphasis placed on standards specific to women. It ranges, for example, from a sentence, selected phrase or short paragraph pertaining to women (typically pregnant women) mixed into the general substance abuse treatment standards, to more detailed subsections specifically outlining women's treatment standards, to lengthier, stand- alone documents on women's treatment requirements. In addition, State standards may vary in which and how many treatment modalities are covered (e.g., residential, outpatient, opioid treatment), and in some cases, may focus on a particular subset of women, such as those involved in the criminal justice system (e.g., Maine) or the TANF program (e.g., Georgia). For those that pertain to pregnant and postpartum women, postpartum may be defined as up to 3, 6 or 12 months after delivery, depending on the State. Moreover, the nature and type of the document in which standards may be found varies significantly. As the table below shows, some States address women's standards in their administrative code or licensing regulations, while others speak to them in contractor requirements. Still others have developed treatment guidelines that represent recommended (but not required) practice. In Florida, for example, the Department of Children and Families and the Department of Health signed a Memorandum of Agreement specifying protocols or operating procedures for how the agencies will collaborate to serve pregnant and postpartum women and their substance-exposed infants. For purposes of this summary we use the term "standards" to encompass all of these types of documents. 2 Chriqui, J.F. et al. (2004). State policy mandates for substance abuse outpatient treatment facilities: Are they quality based? Abstract from presentation at the 132nd Annual APHA Meeting, November 10, 2004. 2 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 Type of Standards Document State* • Licensing/Certification Standards; Arkansas, Colorado, District of Columbia, Florida, Administrative Rules, Regulations or Illinois, Missouri, New Hampshire, North Carolina, Statutes Oklahoma, Oregon, Rhode Island, Tennessee, Texas, Wisconsin, Wyoming • Contract Requirements South Carolina, Texas, Washington • Other Required State Agency Arizona, California, Georgia, Maine, Massachusetts, Standards of Care or Program Nevada, Vermont, Wisconsin Requirements • Guidelines Connecticut, Florida, Hawaii, Idaho, Massachusetts, Tennessee • Specifications in Request for Hawaii, Massachusetts Proposals or Request for Response * A State may be listed in more than one category because it provided multiple documents. 2. "Gender-specific Treatment" – What Does it Mean? What Does it Look Like? Though the majority of States indicate that treatment providers must provide "gender-specific treatment," many do not specify or define what gender-specific treatment means or encompasses. Rather, States may simply assert the need for same gender clinical services or that treatment occurs in the context of a family systems model. Arizona, Colorado, Connecticut, Georgia, Idaho and Wisconsin, however, are examples of States that elaborate on the concept and practice of gender-specific treatment. For example, Arizona emphasizes the importance of a "relational/cultural approach that focuses on the centrality of relationships in women's lives," and Colorado explicitly states, "Program policies and procedures will reflect that women's substance abuse differs from that of men both in its etiology and the treatment of service required for remediation." Georgia defines gender- specific treatment as having: a) gender-specific staff; b) gender-specific services, including prenatal services and child care; and, c) gender-specific therapies including all-female groups, trauma counseling, sexual abuse counseling, non-aggressive/non-confrontational therapy styles, therapeutic parenting skills classes and other recommended services. Wisconsin lays out an overall philosophy—consisting of six core fundamental principles—of working with women with substance use disorders. These core principles address concepts such as the importance of women's relationships in recovery, the provision of wraparound services through inter-systems collaboration and involvement of informal supports, and work as a vital therapeutic tool in recovery. Both Connecticut and Idaho draw on the work of nationally recognized expert Stephanie Covington in outlining the principles or components of gender- responsive treatment. 3. Treatment Services – General. States vary greatly in the level of detail provided when prescribing what treatment services women should receive. Some are very explicit about what services must be provided, while others use more generic, open-ended language. Some go so far as to define expected or maximum lengths of stay, required number of treatment hours per week, and minimum number of beds for women with children. A number of States (e.g., Arizona, Georgia, Idaho, Maine, South Carolina) provide an overview of the various ASAM Levels of Care and what they entail, 3 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 and California describes various treatment modalities in their perinatal treatment guidelines. In addition, States vary in the extent to which a service is required or recommended and must be provided on-site or can be referred out. Several States, such as Idaho and Maine, address the need to use best practices and evidence- based treatment models. Idaho actually provides examples of best practices and effective treatment models, while Maine specifies that treatment should be grounded in proven Motivational and Cognitive-Behavioral practice models (e.g., Motivational Interviewing/Motivational Enhancement Therapy, Cognitive Behavioral Therapy). Wisconsin also indicates that all assessments shall be conducted through motivational interviewing. 4. Continuum of Care. States also vary in the extent to which they address the full continuum of care – from outreach to screening and assessment to treatment to aftercare, recovery maintenance and reentry into the community. Georgia has comprehensive standards in this regard. Typically, though, States will address only certain aspects of the care continuum, and to varying degrees of detail. When it comes to treatment planning, several States explicitly state that clients must receive an individualized treatment plan (Oklahoma and Massachusetts are at least two States that mention treatment plans for both the woman and the child). Connecticut's "recovery plan" is reviewed and revised with the active participation of the client, at a minimum of every 90 days. Nevada also emphasizes that the plan should be client-centered and responsive to the client's preferences. In the area of continuing care, those that do address this service do so to varying degrees, touching on discharge plans, relapse prevention, and recovery community support (see below for more detail on continuing care and recovery community support services). 5. Primary Treatment Services In its Comprehensive Substance Abuse Treatment Model for Women and Their Children, CSAT recommends that treatment providers provide a range of clinical treatment services to women. Below are the primary treatment services that States with women's standards most often address. (Please see Attachment 2 for a more detailed matrix on the specific services outlined in the CSAT Comprehensive Treatment Model that are addressed in the States' standards.) Screening/Assessment. Nearly all (23) of the 28 States reviewed address screening and/or assessment – but to varying degrees of detail. While a State such as South Carolina may generally require "comprehensive biopsychosocial assessments," others, such as Colorado, Connecticut, Idaho, Oklahoma, Oregon, Vermont, and Wyoming are more precise and outline women-specific areas that must be assessed (e.g., trauma, social isolation, domestic violence, parenting). A number of States require the use of the Addiction Severity Index (ASI) or recommend the Stages of Change/Readiness model. Idaho and Georgia also specify other types of screening and assessment instruments must be used. Arizona notes that assessments should be female-specific, while Connecticut says they must be conducted in manner that is sensitive to a history of possible sexual abuse or domestic violence, and possible re-traumatization. Florida has implemented an interagency agreement to ensure a coordinated, multi-agency assessment, and co-locates a Family Intervention Specialist (from treatment program) with Child Protective Services to assist with the substance abuse assessment. Medical Care/Primary Health Care. When it comes to actual clinical services covered in States' standards, all but two address in some form or another, the need to provide or coordinate for medical care for women. Again, the degree of specificity and detail varies 4 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 greatly from State to State. Most often, standards will require providers to ensure that women receive appropriate prenatal and postnatal care, and HIV/AIDS, STDs and TB education, counseling and/or testing. Many other States also include family planning and reproductive health services. A handful of States specifically mention the provision of nutrition (e.g., Arkansas, Colorado, Connecticut, District of Columbia, Massachusetts, and Washington) and tobacco cessation services (e.g., Arizona, District of Columbia, Massachusetts, Oregon, Texas, and Wyoming). Arizona—citing the association between nicotine dependence and poorer birth outcomes—overtly states that "treatment for nicotine dependence should be a routine part of addiction treatment for pregnant women," while Massachusetts requires its family shelters to have an on- or off-site tobacco cessation program. Arizona, Idaho, Massachusetts, and Washington specifically mention or require arrangement for dental services. Mental Health. Of States with standards, 19 include provision or coordination of mental health services for women. Typically this encompasses individual, group and/or family counseling. Wisconsin, however, has adopted more explicit instruction stating that women's treatment providers must "demonstrate the ability to identify concurrent mental health disorders and develop a process to have the treatment for these disorders take place in an integrated fashion with substance abuse treatment and other health care." Arizona calls for all new moms to be evaluated for postpartum depression and psychosis. A few States, such as Arizona, Idaho and Vermont, also specifically mention the need to assess for and address co-occurring eating disorders. Trauma/Violence. States are clearly beginning to recognize and respond to the need for trauma-informed and trauma-specific services for women. While 21 States say that treatment services shall address (either directly or by referral) issues such as past or current physical, sexual or emotional abuse and domestic violence, a few States offer more detailed guidance in this area. Wisconsin, for instance, specifically says that providers must develop a process to identify and address issues related to abuse, violence and trauma and that "services will be delivered in a trauma-informed setting." South Carolina requires residential treatment providers to include "a best practice trauma curriculum" as part of the weekly menu of services provided; a trauma curriculum is also indicated as a major treatment component for intensive outpatient and day treatment. Colorado is one of the States that stands out in its emphasis on trauma, requiring treatment program policies, procedures and service delivery to understand, recognize and address the interplay between substance use and trauma symptoms. The standards also state that the emotional and physical safety of clients shall take precedence over all other considerations in the delivery of services. New Jersey requires that all services be trauma informed and trauma specific, while Massachusetts encourages the integration of trauma services into substance abuse treatment system and continuum of care, and provides a definition of trauma informed services. Substance Abuse Counseling and Education. While the majority of States (20) reviewed require some type of substance abuse education and counseling, the issues and topic areas covered vary. Oklahoma, for example, simply states that residential treatment services are to include educational groups. A number of States focus their education requirements on substance use during pregnancy. Texas, for example, requires providers to use "evidence-based curricula for education on substance use, abuse and effects of ATOD on the fetus," while the District of Columbia requires that clients receive a minimum of 1 hour of educational per week on the effects during pregnancy. New Hampshire indicates pregnant women must be counseled, among other things, on the importance of informing medical practitioners of alcohol and other drug use during 5 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 pregnancy. California extends substance abuse education to the effects during breastfeeding, while Oregon's opioid treatment programs must ensure a pregnant woman is fully informed concerning risks to herself and unborn child from use of the methadone, as well as other drugs and alcohol. Other States (e.g., Colorado, Georgia, Missouri, Washington) cast a broader net regarding substance abuse education, touching on issues such as impact on family, relationships, sexuality, self-esteem, gender roles, domestic violence, and other issues. Washington, for instance, requires 20 hours of education and treatment per week that covers issues such as the biological, physiological, and social effects of ATOD; denial; relapse and relapse prevention; chemical dependency behaviors and co-dependency behaviors; symptom of disease; anger management; meditation and stress reduction; and the 12 steps. Continuing Care/Aftercare/Recovery Management. As stated above, the 20 States that do address this area do so to varying degrees. Wisconsin, for example, requires treatment providers to conduct an assessment prior to discharge, design a written discharge plan, make and document appropriate referrals and remain available to the client as a resource for support and encouragement for at least one year following discharge. In contrast, Texas states more broadly that services under the treatment plan will include follow-up services to prevent relapse, and that providers must coordinate with other services and resources to including continuing care for pregnant, postpartum and parenting women. And Georgia's standards, which are targeted to TANF recipients, require that women receive an aftercare plan that includes random urine drug screens within the first three months after discharge. (See also "recovery community support services" below.) The duration of continuing care also varies by State. Massachusetts, for example, provides aftercare (which addresses family reunification, among other things, for certain clients) for up to 3 months after discharge. New Jersey, however, requires monthly face-to-face contacts for up to 12 months, while Arkansas calls for monthly follow-up contacts for a minimum of one year. Pharmacotherapy. Standards related to pharmacotherapy typically focus on pregnant women, often noting that pregnant women may be exempted from minimum admissions requirements and should undergo monthly pregnancy tests. State policies may also address withdrawal from maintenance therapy. For instance, Arizona and Colorado state that medically monitored maintenance therapy should be continued throughout pregnancy, and Wisconsin indicates that withdrawal should not be initiated before the 14th week or after the 32nd week of pregnancy. In addition, State standards that cover pharmacotherapy often require that treatment programs must admit and accommodate clients on MM or other opioid pharmacotherapy, and such therapy may not be a basis for exclusion from a treatment program. Arkansas states that pregnant women cannot receive LAAM. Drug Monitoring. Only a few States address issue of drug monitoring or testing in their standards. Georgia states that ongoing services should include drug screens and 3 to 6 (varies depending on level of care) random urine drug screens within the first 3 months after discharge. New Jersey requires a minimum of 4 to 6 random urine samples over course of treatment (again, varies depending on level of care). Other States are less prescriptive. Idaho, for example, indicates random urine testing should be used where clinically appropriate, and Florida's guidelines merely state that women should consent to drug toxicology and be informed about possible uses of the test results. 6 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 6. Support Services The CSAT Comprehensive Treatment Model also outlines an array of clinical and community support services for women and their children and families, much of which is designed to strengthen family functioning and increase a woman's self-sufficiency. Below are the support services most often covered in the State standards reviewed. Attachment 2 provides additional information on other support services – such as transportation, housing, life skills training and education, and recreational services – that are addressed in the State standards. Parenting and Child Development Education. Not surprisingly, developing parenting skills, promoting parent-child bonding, and strengthening parent-child interaction are areas of emphasis for nearly all (86 percent) of the 28 States reviewed. Child development education may encompass coping skills, ways to redirect children's misbehavior, effective and appropriate discipline, breastfeeding, child safety and other issues. The District of Columbia, for example, lays out very specific requirements that include preparing a detailed written plan and schedule of parent-child bonding activities that includes minimum hourly bonding, child development education and parenting skills training requirements. Similarly, Washington State requires providers to develop and document an individualized parenting education plan within 14 days of admission. And Wyoming notes that residential treatment for women with children must be integrated with a woman's responsibilities to children, and mandates that treatment include at least 30 hours a week of services that include parenting, family reunification and child development. Oklahoma's requirement is slightly less – at least 24 hours a week of substance abuse, parenting and child development services. While States do not dictate what parenting curriculum is implemented, Massachusetts does require it to be evidence-based. Family Programs/Family Strengthening. Of the State standards reviewed, 86 percent (or 24 States) also recognize and acknowledge that women function within a larger family system, that a woman's substance abuse must be addressed in the context of her children and family, and that treatment services should involve a woman's spouse, partner or other family members in a woman's recovery (as appropriate) and provide services to the family as a whole. Typically, States will require services to include, at minimum, family counseling and basic substance abuse prevention education and support skills (e.g., crisis, anger and behavioral management, relapse prevention, communication, relationships). Some States (e.g., Florida, Wisconsin) broaden this notion, stating that providers must identify and address the needs of family members through direct service, referral and/or other processes. States may also define "family" differently. Both Massachusetts and Wisconsin define family broadly to include whoever the client identifies or chooses as family, while Hawaii says family may involve parents, children, partners or other significant others within the client's home environment. A few States (e.g., Connecticut, Vermont) specifically address reunification plans, if appropriate, and the need to consider The Adoption and Safe Families Act (ASFA) or other mandates. Idaho even offers examples of recommended programs, including the Multi-family Group (part of the Matrix Model) and the Celebrating Families educational support group for parents in early recovery and their children. Among all States, however, Massachusetts is distinctive in its efforts to expand the concept of family-focused treatment and require programs to provide family-focused treatment and target more services for the children, as a means to promote recovery, increase family integration and reduce the intergenerational transmission of substance abuse related problems. The Bureau of Substance Abuse Services notes that "family- 7 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 focused treatment means programs recognize that most clients in our system are either connected with family when they begin the treatment process, will re-connect with family in the recovery process, or will form new family ties in recovery. Paying attention to this dimension and supporting clients as they are re-forming and re-defining these relationships in recovery is very important in relapse prevention." Linkages with Child Welfare Systems, Courts/Criminal Justice and TANF. Twenty States address the need for treatment providers to coordinate and communicate with the courts and/or child welfare systems (where applicable), but again to varying degrees. South Carolina, for example, notes that providers should work with the Department of Social Services and encourage and provide every opportunity for parenting women to visit with their children. Others are more prescriptive in this area. Texas, for example, states that all efforts will be made to participate in the family reunification plan with the custodial agency. It further requires providers to work with the court and the client to meet court conditions and reunite the family. Washington requires treatment providers to develop agreements with Division of Children and Family Services (DCFS) social workers for parents whose children are involved with DCFS regarding on-site visits or conference calls, schedule of court dates, providing copies of the individual service plan prior to court dates, obtaining basic information about the child (e.g., behavior, medical status), and other related issues. Hawaii also addresses the need for working written agreements with child protective services (CPS) that delineates the responsibilities of the treatment program and CPS. New Jersey is specific in its provision that interdisciplinary meetings with child welfare services and/or the courts should start within 30 days to incorporate a client's case plan into the treatment plan, and continue at least once a month. Other States are less explicit, but still address the need for linkages: Idaho, for instance, indicates treatment programs should facilitate a team approach that integrates treatment with criminal justice system requirements and interventions. Idaho also indicates efforts should be made to obtain appropriate consents for information sharing from other systems the woman is involved in and to develop an effective team approach to her services. Though "linkages" are not specifically mentioned, Arizona's protocol includes a special section on the unique needs of women with substance use disorders involved in the criminal justice system and discusses the importance of specialized addiction treatment for pregnant women offenders. A smaller number of States (7) address linkages with TANF. This concept is woven throughout Georgia's standards, which are focused on women who are TANF participants. While Florida calls for substance abuse treatment providers to co-locate TANF outreach workers at TANF service sites to systematically screen TANF clients, other States very briefly and generally mention the need to partner or coordinate with welfare agencies. Educational/Vocational Support and Employment Readiness and Support. Nearly two- thirds (18) of the States reviewed require or recommend that treatment services include basic adult education/GED and literacy, vocational training, education and experience, and similar support services to help promote self-sufficiency. A somewhat smaller number of States (13) specifically address employment readiness and support, such as job skill assessment and training, or development of an employment plan. North Carolina, for instance, calls for interactive training for employment and indicates that a component of therapeutic communities may be business training schools (e.g., moving and storage, landscaping, construction, telemarketing, secretarial and clerical, retail sales). Connecticut notes that clients should be compensated for work provided within the organization, if available, while Nevada states that clients who are already employed 8 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 and in the process of recovery should receive any needed assistance with work-related problems. Recovery Community Support. Nineteen States address the need to provide recovery community support services. Georgia, for example, requires the provision of self-help groups during treatment and as part of a woman's aftercare. South Carolina, in addition to requiring recovery community support in residential treatment, also notes that self- help group orientation is a major treatment component of intensive outpatient and day treatment, which allows women "the opportunity to test new coping strategies while in a supportive environment." And Wisconsin states that the ultimate goal is to "weave the woman so well into the fabric of informal support systems that the role of formal services is very small or not needed at all." Connecticut also emphasizes a recovery system of care and the extensive use of family and community systems for long-term recovery support. It indicates that peer supports within program should be clearly established (e.g., women in more advanced levels of treatment mentoring those beginning), while also connecting the woman to local family support, advocacy groups and, if requested, faith-based support, prior to discharge. In addition to integrated self-help and peer groups, Nevada also urges follow-up to re-engage clients who may have disengaged from support groups. Child Care. The majority of States (21) expressly require child care to be made available while women are in treatment and rehabilitative activities. In fact, Tennessee refers to this as an "essential aspect" of services to women, and indicates that child care should include as assessment of the child's life functioning areas, and may include other services such as child counseling, play therapy and mother-child therapy. Typically standards related to child care apply to children up to age 12 or 13. While Georgia requires on-site therapeutic child care for children 13 and younger in residential treatment facilities, California requires on-site child care for children 0 – 36 months, and then gives providers the option of providing such care either on- or off-site for children 37 months – 12 years. Idaho is unique in that it calls for creating a plan for respite care, which includes at least three sources the mother can call upon. Additional information on children's services is provided below. 7. Mothers in Treatment with Children. When it comes to the issue of children accompanying their mother in treatment, some States (such as Washington, DC and Georgia) are quite explicit in their requirement that children accompany their mothers in treatment, unless contraindicated for medical, legal or other reasons. Idaho states "The key is that children are treated in the same setting as their mother." Others, however, use less directive language such as, "Admission of children shall depend on program's ability to provide the needed services," (Oklahoma) or "Program shall endeavor to provide services in facility that accommodates the presence of the children" (Wyoming) or "Ideally, women will live with their children during residential treatment" (Arizona). Further, there are differences among States when it comes to age limits of children admitted with their mom, and the number of children per resident. Massachusetts is atypical in stating that all children up to age 18 years are eligible to live with their parent (in family residential substance abuse treatment programs). In contrast, other States may limit it to children up to age 3 or 5 years. New Jersey allows women to enter treatment without their children for the first 30 days, after which at least one child can join the mother, if space is available. 9 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 8. Children's Services. In addition to clinical treatment and support services for women, CSAT's Comprehensive Model also identifies a range of services that children of women with substance use disorders should receive. While no State standards explicitly covered the broad spectrum of children's services outlined in the model, many States did address the needs of children's to some degree. This information is broken down generally into a) screening and assessment and b) services, and summarized below. Screening and Assessment. Sixteen of the States reviewed include requirements and/or recommendations – again, to varying degrees – regarding children's screening and assessments. On one end of the spectrum, for example, are States that simply say infants and children 0 to 3 years of age will be referred for early childhood intervention screening. Others elaborate further. Arizona, the District of Columbia, Oklahoma and Washington State, for example, outline different areas (e.g., mental health, social/emotional/behavioral development, educational needs, parent-child relationships, sibling relationships) that children's assessments should include. And while the District of Columbia requires a developmental assessment to be done within 3 days of a child being admitted, Washington State requires it to be completed within two weeks, Georgia gives providers 30 days, and Missouri states it must be done before the child receives any services beyond child care and community support. Georgia is one of the only States to list the various screening and assessment tools that may be used and for what ages they are appropriate (e.g., Achenbach Child Behavior Checklist, Denver II, BRIGANCE Diagnostic Inventory of Early Development). Most States address the need for a child's health/medical screening. Idaho, however, specifically notes that this should include an evaluation of fetal alcohol and drug effects, as well as use of the Trauma Symptom Checklist for Children. And Florida's interagency agreement is intended to ensure a coordinated, multi-agency assessment of the health, safety and other service needs of substance-exposed children. Services. Eighteen States address, in some fashion or another, what services should be provided to the children of women in treatment. In general, children's services are less well-defined and vary more in focus and content. Most all require the provision or arrangement of primary pediatric care, including immunizations. Arizona also notes that babies exhibiting neonatal abstinence symptoms undergo safe and comfortable detoxification. Similarly, Texas requires that infants and children receive treatment for any perinatal effects of maternal substance abuse. The District of Columbia and Missouri both use the same language in calling for age- appropriate activities that will facilitate the parent's recovery goals as well as help children achieve various goals, such as building self-esteem, learning to identify and express feelings, and developing decision-making skills. Along these lines, Massachusetts addresses the need for support, education and mentoring to children, while Idaho recommends the use of the Celebrating Families educational and support program. Several States stress the importance of early intervention services. Massachusetts, for example, necessitates the development of a prevention and early intervention system, which recognizes their special issues and needs of children to prevent them from developing their own substance abuse problems as they mature. New Jersey's general statutes state that early intervention services provided to children under age 3 and their families may include early identification and screening, multidisciplinary evaluations, case management services, family training, counseling and 10 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 home visits, psychological services, speech pathology and audiology, and occupational and physical therapy. At least five States address the provision of therapeutic child care. Of these, Georgia includes a whole section on therapeutic child care requirements, including staffing patterns, ratios and outcomes. Further, all its residential programs must implement The Nurturing Program as the standard for their therapeutic child care. Washington State also provides specifics about therapeutic child care staff-to-child ratios, and indicates such care must be provided for a minimum of four hours a day, five days a week. Oklahoma requires its residential treatment centers to provide children aged 3-12 with a minimum of 12 hours of therapeutic services a week, with special attention to high risk of sexual abuse, sexual acting-out by children, and suicide risk and treatment. Other States may couple specific requirements with more open language. South Carolina, for example, requires its intensive outpatient programs to provide a "specialized children's program that enhances healthy development and meets the physical, psychological, social and educational needs of each child." Yet it also indicates that each child must receive a minimum of three hours a week of structured intervention and school-age children receive monthly therapeutic sessions that include parent-child interaction. And while Texas states broadly that children shall receive services to address their needs and support healthy development, it also explicitly requires that infants and children receive, either directly or by referral, counseling and other mental health services and referral to comprehensive services. And Wyoming, which says children shall receive age-appropriate therapy as needed, also states that children must be provided with access to a full range of services including transportation, educational services, well-child health care, emergency health care, health and speech/language screenings, dental care, and hearing and vision. Washington State is unique in that it requires its women and children residential programs to develop and maintain a Child Services Program Manual and spells out the various policies and procedures to be included, as well as services to be provided. 9. Pregnant Women With regard to pregnant women specifically, most States have a common set of standard regulations that typically reflect the SAPT Block Grant requirements, such as pregnant women get priority treatment admission and must be admitted within 48 hours (or provided with interim services if not able to admit). California provides the most comprehensive list of interim services. Strong emphasis is also placed on ensuring that pregnant women receive prenatal care and education on the effects of substance use during pregnancy. About a dozen States include specific language regarding methadone or other opioid replacement treatment that typically provide policies regarding admission, detoxification or withdrawal, pregnancy testing, and education and counseling. Colorado and New Jersey both state that pregnant women may not be discharged from substance abuse treatment solely for failure to maintain abstinence. Illinois emphasizes the need for linkages with medical care and other providers serving pregnant women and the development of special programs for case finding and service coordination for pregnant women with substance use disorders. Georgia, too, underscores the importance of a multidisciplinary, cross-systems collaborative approach in working with pregnant women. 11 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 10. Outcomes/Monitoring. About a dozen State standards contained information regarding program outcomes and the monitoring/tracking of clients. (Again, this may be an area that is more often covered in the general standards applicable to all treatment providers.) Standards that did touch on this area typically included general record-keeping requirements (e.g., a program shall document any services provided) or other standard performance monitoring (e.g., submission of regular progress reports). South Carolina, Georgia and Arizona were States that elaborated in this area. South Carolina, in addition to semi-annual narrative reports that include outcome evaluations, requires residential programs to conduct 6- and 12-month follow-up of clients to determine program effectiveness. It also requires intensive outpatient programs to evaluate their children's services curriculum annually and submit any changes for approval. Arizona, too, requires outcome categories to be measured at baseline, regular intervals (e.g., 30, 60, 90 days of treatment, then every 1-2 months throughout treatment), discharge, and changes in treatment level of service. Arizona's standards also include an extensive section on desired outcomes that outlines signs, symptoms and behaviors; targets; and measurements for addiction treatment generally, as well as gender-specific treatment. Similarly, Georgia's program requirements include a section dedicated to expected outcomes and reporting requirements. Nevada's standards are structured around five categories, one of which is outcome measurement; further, its standards encourage providers to fully implement the State Outcomes Measures (derived from the Federal National Outcome Measures). Georgia and Maine both require the collection of specific data using certain tools. For instance, Georgia's residential programs must implement the pre/post test of The Nurturing Program (the standard for the therapeutic child care) and use the computerized version of the AAPI to measure the effectiveness of their therapeutic child care's parenting component. Maine requires the use of six standardized instruments – Alcohol and Drug Refusal Self-Efficacy Questionnaire (ADRSEQ), Drug Avoidance Self-Efficacy Scales (DASES), Coping Behaviors Inventory (CBI), Commitment Scales (CS), Problem Solving Questionnaire (PSQ), and Perceived Modes of Processing Inventory (PMPI) – as well as a Client Satisfaction Questionnaire. This battery of assessments is used for ongoing assessment, as well as treatment planning and outcome evaluation measures. Other States list general areas for both performance and outcome measures. Hawaii, for example, includes employment status, living arrangements, psychological distress, days or work/school missed due to substance use, arrests, emergency room visits, and hospitalizations, while Connecticut includes the appropriate utilization of gender responsive treatment services and short- and long-term impact of interventions on program participants in 10 domains. Massachusetts adds increased stability and preservation of the family system to outcomes measures for its specialized pregnant and parenting women with children programs. New Jersey's programs must measure child welfare outcomes in the areas of safety, permanency and well-being of children, while improved parenting is an expected outcome of residential programs in North Carolina. In addition, Indiana conducts ongoing quality improvement activities that include reviewing a sample of case management and other services provided to identify opportunities to improve services. 11. Staff Training. Sixteen of the States reviewed included some type of language about staff training and development in their women's treatment standards – but again, it varies greatly in breadth, depth and specificity. For instance, a State may require quite generally that staff have training in the area of gender-specific women's substance abuse modalities and treatment skills or in 12 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 therapeutic issues relevant to women and children. Other States expand upon this and actually identify particular issues relevant to women, such as domestic violence, trauma, child abuse and neglect, grief and loss, impact of substance abuse on parenting and family units, and traditional and non-traditional community supports. (North Carolina requires staff training on these and other issues within 60 days of employment.) And still others (North Carolina, Oklahoma, Texas, Wyoming) take it a step further to include children's issues – requiring, for example, that treatment staff have specialized training in child development, early childhood education, age-appropriate behaviors, effects of prenatal alcohol or drug exposure on child development, recognition of sexual acting-out behavior and other issues, signs and symptoms of pre-term labor and postpartum depression, dynamics and needs of children diagnosed with ADD/ADHD, and infant feeding, including breastfeeding. Maine also specifically requires training on Motivational Interviewing/Motivational Enhancement Therapy, and "extensive training in program delivery and administration, scoring, and tracking of the applied psychometric measures," complete with quarterly booster training events. 12. Staff Qualifications. In terms of staff qualifications (e.g., background and education), some States single out certain service areas in which they discuss staff qualifications. For example, California outlines which staff are eligible to conduct children's assessments, while Washington indicates what staff may provide on-site health care visits and consultation. Georgia and Washington provide specific requirements for therapeutic child care staff (e.g., program director, program supervisor, teachers/lead caregivers, and caregivers/aides), and Idaho's Targeted Intensive Case Management staff include an intensive case manager, early child development/parenting specialist, and behavioral health specialist. Other States explicitly state the need for female staff. Arizona, for example, says staff must include female role models, including women in management positions, and counseling staff should be predominantly female, including women in recovery. Connecticut also notes that the majority of staff members should be women. (Staff education and professional requirements is also likely an area in which States provide more information in the general standards applicable to all treatment providers.) 13. Miscellaneous/Other In addition to the above themes that emerged, there are also some unique aspects to select State standards that fall outside the above categories but deserve mention. For instance, the Illinois Alcoholism and Other Drug Dependency Act established a Committee on Women's Alcohol and Substance Abuse Treatment to provide the State with input and recommendations on how to best address the intervention, prevention and treatment needs of women and ensure effective service delivery to women (among other duties). South Carolina requires residential programs to have and use an Advisory Committee, the composition of which "should be consistent with the population to be served and include consumers." The District of Columbia includes a related provision: it requires a program's governing board to include "members with special interest in expertise related to programs and services for parent(s) and children." In addition, Massachusetts is requiring bidders for residential family substance abuse treatment to participate in regularly scheduled meetings to develop standards of care, including minimum staffing and clinical treatment hours. Florida's guidelines represent a nice example of a collaborative model to address the needs of pregnant and postpartum women with substance use disorders and substance-exposed children. Florida also has a "last resort" involuntary commitment to substance abuse treatment option for pregnant or postpartum women who are abusing alcohol or other drugs, which – if 13 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 specific criteria are met – enables a caregiver to contact a law enforcement officer to implement protective custody measures or petition the Circuit Court for court-ordered involuntary treatment. There are two aspects to Nevada's standards to mention. The first is a special emphasis on client-centered care and client empowerment. The second is the requirement for all funded programs to have national certifications, such as Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Commission on Accreditation of Rehabilitation Facilities (CARF), or Council for Accreditation for Children and Family Services (COA), by 2009. A final aspect to point out relates to funding. In New Jersey, contracting requirements state that programs must develop a system for allocating, tracking and differentiating revenue, expenses, services and capacity by payor to provide a comprehensive view of their service programs. And in Massachusetts, the Bureau of Substance Abuse Services is working with its partners to identify payor mechanisms to support programs that want to offer parenting as part of the services and explore integrated systems for clients' children to receive treatment, as needed. III. KEY ISSUES/AREAS TO ADDRESS IN DEVELOPING GUIDANCE TO STATES ON WOMEN'S TREATMENT STANDARDS The treatment standards questionnaire also asked the WTCs to identify the key issues or areas that NASADAD should address in developing guidance to the States on women's treatment standards. Below are the common themes that emerged from the open-ended comments provided by 44 States. • Children's Services/Family Services. Services for women in treatment and their children and families was one of the most frequently cited issue areas by the WTCs. Approximately 25 comments from 19 States fell into this category. Comments ranged from the need for standards guidance to address generally the provision of child and family services (including women's children who may be in foster care), to tackling more specialized treatment issues, such as family dynamics, children's developmental services, trauma and attachment, family members' co-occurring disorders, and FASD. Several WTCs also expressed the desire for standards to address licensing regulations and other standards regarding child care and therapeutic child care, as well as parenting skills. Other comments discussed the need for State, private and public collaboration to reinforce and address the needs of the family, including improved procedures and policies between State child welfare and substance abuse agencies. • Evidence-based Practices and Gender-Specific/Competent Treatment. The other major area that WTCs would like addressed in guidance around standards concerns evidence- based practices for women (including pregnant women) and gender-specific treatment approaches. More than 20 comments from 16 States touched on this subject area. Similar to the topic area of children and family services, comments were both general in nature (e.g., definition of gender-specific treatment) and quite specific (e.g., guidance related to number of treatment hours in specialized areas such as parenting, domestic violence, trauma, etc.; appropriate screening for pregnant women; and placement and length of stay as it relates to client need and treatment outcomes). • Access, Retention and Continuing Care/Aftercare. Comments from approximately 10 States could be categorized generally around continuum of care. Several identified the need to continue to address access to treatment (including wait times) and barriers to treatment retention. A couple of WTCs would like standards to incorporate length of stay requirements to enhance women's success in treatment. Several States also highlighted the need for 14 May 20, 2007 Prepared by Children and Family Futures under CSAT Contract No. 270-03-7148 standards to include continuing care and clearly defined aftercare plans to ensure a smooth transition back into the community. • Trauma and CODs. The provision of trauma-informed and trauma-specific services, and treatment for other co-occurring disorders, is another significant area that 14 of the States would like to see addressed in treatment standards. States expressed a need for guidance in education, assessment, and treatment protocols to adequately respond to a woman's trauma and victimization. • Funding. Many of the States (15) provided comments related to treatment funding and payment. Several of these comments focused on the need for guidance regarding integrated, shared or coordinated funding with other sources, and how to leverage additional funds to support and sustain women-specific programming and any detailed changes in women's treatment standards. Others centered specifically on Medicaid coverage for services. In addition, a couple of States indicated a need to address reimbursement rates for providers. • Other System Issues (Collaboration, Data, Staff Training/Workforce Development). About a dozen States provided comments on other types of service delivery systems issues. Several mentioned the need for standards guidance to cover data collection and information sharing, and collaboration with other service providers (generally and on specific issues such as detoxification). In addition, many (8) States identified the need to deal with staff qualifications, certifications and credentialing, and ongoing training and technical assistance on women's treatment issues. • Methadone/Pharmacotherapy. Six States would like standards or guidance regarding standards to contain information on methadone maintenance and acceptable pharmacotherapy for women. • Other or General Services for Women. In the comments received, WTCs also touched on several other services they felt were important for women's treatment standards to address: housing, physical health needs, vocational training and support, life skills, and access to and provision of community services. • Other Special Subpopulations. A number of States also highlighted specific subpopulations of women to consider in the development of treatment standards guidance, including women who use methamphetamine, women involved in the criminal justice system, and women across the lifespan (including teenagers and older women who are no longer parenting). In addition to these specific treatment issues that States said they would like to see addressed, many of the comments related to bigger-picture concerns, which speak to the future direction of the overall development and implementation of women's treatment standards. These included, for example, the need for uniformity and consistency across the States; questions and concerns about how to make standards a contractual or regulatory requirement for all providers (not just those receiving SAPT Block Grant funding); how to incorporate any new standards into existing State standards; ensuring the participation of other key systems, service providers and consumers in the process; ensuring standards or guidelines are consistent with the National Outcomes Measures (NOMS); and how to continue and increase national, State and local support for women's treatment. 15 ATTACHMENT 1: LISTING OF STATES AND STATUS OF TREATMENT STANDARDS FOR WOMEN AND/OR PREGNANT WOMEN (as of April 30, 2007) STATES WITH STANDARDS (28) Arizona – Practice Improvement Protocol 5: Substance Use, Abuse, and/or Dependence in Pregnant and Postpartum Women. Developed by the Arizona Department of Health Services, Division of Behavioral Health Services. Effective July 9, 2001; Last Revised April 3, 2003. Arkansas – Licensure Standards for Alcohol and/or Other Drug Abuse Treatment Programs. Arkansas Department of Human Services, Division of Behavioral Health Services, Alcohol and Drug Abuse Prevention. Revised January 1, 2004. California – Perinatal Network Services Guidelines 2004 (For Non Drug Medi-Cal Perinatal Programs), California Department of Alcohol and Drug Programs. Colorado – Substance Use Disorder Treatment Rules. Colorado Department of Human Services, Alcohol and Drug Abuse Division. 15.229 Gender-Specific Women's Treatment and 15.230 Services to Child Welfare Clients. Working Copy, February 27, 2007. Connecticut – Treatment Guidelines – Gender Responsive Treatment of Women with Substance Use Disorders. Connecticut Department of Mental Health and Addiction Services, Women's Services Practice Improvement Collaborative. Revised January 2007. District of Columbia – Department of Health, Chapter 23 Certification Standards for Substance Abuse Treatment Facilities and Programs. Section 2357 - Specialty Services − Additional Standards for Programs Serving Parents and Their Children; Section 2358 - Specialty Services − Standards for the Developmental Assessment of Children (2000). Florida – Florida Substance Abuse Licensure Rule 65D-30, Florida Administrative Code, Specific References in Rules to Females; and Guidance for Working With Pregnant and Postpartum Women Who Abuse Drugs or Alcohol, Children Prenatally Exposed to Drugs Or Alcohol, and Their Families, Florida Department of Health and Florida Department of Children and Families, October 2003. Georgia – Ready For Work: Community Substance Abuse Services for Pregnant and Postpartum Women and Women with Dependent Children. A Program of the Department of Human Resources to Assist Recipients who meet the Needy Family Definition. Program Requirements for Community Mental Health, Mental Retardation and Substance Abuse Providers Under Contract with Regional Boards and Required Linkages with Other Responsible DHR Programs. Georgia Department of Human Resources, Division of Mental Health, Mental Retardation and Substance Abuse. Issue Date: March 25, 1998; Revision Effective: July 1, 2007. Hawaii – Section 2 - Service Specifications. Specialized Substance Abuse Treatment and Therapeutic Living Program for Women, Pregnant Women and Parenting Women on Maui (RFP 440-1-8); Section 2 - Service Specifications. Specialized Substance Abuse Treatment Services for Pregnant and Parenting Women (RFP 440-1-7); Section 2 - Service Specifications. Baby SAFE - A Specialized Substance Abuse Outreach and Early Intervention Service for Pregnant Women on Kauai (RFP 440-1-9); and Substance Abuse Treatment Guidelines, Best Practices/Evidence-Based Practices. Department of Health, Alcohol and Drug Abuse Division. Effective July 1, 2002. Idaho – Pregnant Women and Women with Children Treatment Service Continuum. State of Idaho. Effective July 2006; Revised December 2006. Illinois – Chapter 20, Executive Branch, Department of Alcoholism and Substance Abuse. Act 301. Alcoholism and Other Drug Abuse and Dependency Act. Article 35 – Special Services for Pregnant Women and Mothers. Effective July 13, 1993. Maine – Differential Substance Abuse Treatment (DSAT) Model. Developed for the State of Maine, Department of Health and Human Services, Office of Substance Abuse (OSA) and Implemented in the State of Maine Department of Corrections (MDOC) Institutions and the Statewide Adult Drug Treatment Court (ADTC) Programs. March 2005. Massachusetts – Fiscal Year 2007 Request for Response, Terms and Conditions and Standards of Care for the Alcohol and Other Drugs Service System. The Massachusetts Department of Public Health, Bureau of Substance Abuse Services, Fall 2006; Request for License Application and Renewal Form. Massachusetts Department of Public Health, Bureau of Substance Abuse Services, September 13, 2001; Request for Response, Residential Recovery Services &Family Residential Substance Abuse Treatment Services in Boston; and Massachusetts Department of Public Health, Bureau of Substance Abuse Services, Family Substance Abuse Shelter Guidelines. Missouri – Rules of Department of Mental Health. Division 30 – Certification Standards. Chapter 3 – Alcohol and Drug Abuse Programs. Title 9 CSR 30-3.190 Specialized Program for Women and Children. (Also includes other excerpts that are related to women.) June 30, 2005. Nevada – Substance Abuse Treatment Program Operating And Access Standards (POAS), Department of Health and Human Services, Division of Mental Health and Developmental Services (MHDS), The Substance Abuse Prevention and Treatment Agency (SAPTA), New Hampshire (pregnant women only) – Chapter He-A 300 Certification and Operation of Alcohol and Other Drug Disorder Treatment Programs. Part He-A 301 Certification of Alcohol and Other Drug Abuse Disorder Treatment Providers. Statutory Authority: RSA 172:8-b. 5/23/01. New Jersey – N.J.A.C. TITLE 8, Chapter 42A Manual of Standards for Licensure of Residential Substance Abuse Treatment Facilities; Annex A – Contract Number: 08-ADA-0 (boilerplate); Annex A – Section III - Requirements for Specialized Women's Services Programs, March 2006; Annex A – Residential CWRP/DYFS/Women & Children's Program, September 8, 2006; Annex A -- Division Of Addiction Services (DAS)/CWRP, General Funding Requirements March 1, 2007 - February 29, 2008; Annex A – Variable Level Of Care, CWRP/DYFS/Women & Children's Program, March 14, 2007; and Annex A, Section III, Requirements For Women's Set Aside Methadone Maintenance, September 11, 2006 North Carolina – Rules for Mental Health, Developmental Disabilities and Substance Abuse Facilities and Services, 10A North Carolina Administrative Code 27G, Section .4100 Residential Recovery Programs for Individuals with Substance Abuse Disorders and their Children, Department of Health and Human Services, Division of Mental Health, Developmental Disabilities and Substance Abuse Services, April 1, 2006; Enhanced Benefit Services for Mental Health and Substance Abuse, Effective March 20, 2006; and North 2 Carolina General Statutes, Chapter 122C. Mental Health, Developmental Disabilities, and Substance Abuse Act of 1985, Sections 122C-211 (f) and (g). Oklahoma – Oklahoma Department of Mental Health and Substance Abuse Services. Title 450, Chapter 18 – Standards and Criteria for Alcohol and Drug Treatment Programs. Part 13: Residential Treatment for Persons with Dependent Children; Part 21: Halfway House Services for Persons with Dependent Children. July 1, 2006. Oregon – Oregon Administrative Rules, Standards for Outpatient and Residential Alcohol and Drug Treatment Programs, 415-051-0110 Women's Treatment Services & Division 20 Standards for Outpatient Synthetic Opiate Treatment Programs, 415-020-0025, August 16, 2004. Rhode Island – Rules and Regulations for the Licensing of Behavioral Healthcare Organizations, State of Rhode Island and Providence Plantations, Department of Mental Health, Retardation and Hospitals, September 2004. South Carolina – Policies regarding women's treatment are reflected in the contracts between the South Carolina Department of Alcohol and Other Drug Abuse and the local providers. Definition, service activity and special conditions outlined for levels of care. Tennessee – Administrative & Program Requirements and Scopes of Services, Tennessee Bureau of Alcohol and Drug Abuse Services. Effective July 1, 2006; revised August 8, 2006; Tennessee Alcohol and Drug Best Practice Guidelines, Tennessee Department of Health, Bureau of Alcohol and Drug Abuse Services, September 2001. Texas – Chapter 447 Contract Program Requirements, Subchapter A. Prevention and Intervention, §447.116. Pregnant and Parenting Adult and Adolescent Female Prevention Services. Subchapter F. Treatment for Pregnant and Postpartum Women with Dependent Children. September 1, 2004; and Chapter 448 Substance Abuse Standards of Care Rules, Subchapter C. Standards for Evidence-Based Prevention Programs, Subchapter I. Treatment Program Services, §448.901 Requirements Applicable to all Treatment Services, §448.903 Requirements Applicable to Residential Services, §448.904 Requirements Applicable to Outpatient Treatment Programs, §448.910 Treatment Services for Women and Children, September 1, 2004. Vermont – Gender Responsive and Trauma Informed Services for Women and their Children. March 2007. Washington – Pregnant, Postpartum, Parenting Women – Residential Treatment Statement of Work. March 2005. Wisconsin – Wisconsin Department of Health and Family Services. Vision Statement and Core Values. Philosophy of Working with Women with Substance Use Disorders. Treatment Standards for AODA Services to Women; and Chapter HFS 75, Community Substance Abuse Service Standards (primarily HFS 75.15 Narcotic treatment service for opiate addiction). Wyoming – Department of Health Substance Abuse Division, Rules and Regulations for Substance Abuse Standards, Chapter 16, Section 17 – Special Population Designation(s): (c) Women's Treatment Services and d) Residential Treatment for Persons with Dependent Children. 3 STATES THAT WERE DEVELOPING STANDARDS (3) Alabama Louisiana Maryland * New Jersey, which has standards for women, is also in the process of developing standards for pregnant women. STATES THAT INDICATED THEY DID NOT HAVE STANDARDS (20) Alaska Delaware Indiana Iowa Kansas Kentucky Michigan Minnesota Mississippi Montana Nebraska New Mexico New York North Dakota Ohio Pennsylvania South Dakota Utah Virginia West Virginia 4 Revised 5-8-07; reflects information from standards collected & reviewed as of April 30, 2007 ATTACHMENT 2: CLINICAL TREATMENT AND SUPPORT SERVICES* FOR WOMEN ADDRESSED IN STATE STANDARDS (*As recommended in the CSAT Comprehensive Treatment Model for Women and Their Children) Note: A check mark in a given service category means that this service was in some way mentioned or identified in a State's treatment standards/protocols/guidelines for women and/or pregnant women. However, as we indicated in the summary of key themes, the degree to which States address and elaborate on a particular service may vary greatly. It is important to note that a State also may address these service areas in its general standards applicable to all treatment providers, regardless of population served. This review only focuses on women-specific materials; it does not include information from general or universal standards that may address these areas. WA WY MO MA CO GA ME OK OR AR CA DC NH NC NV SC AZ CT TN NJ TX VT FL WI State HI ID RI IL CLINICAL TREATMENT SERVICES Outreach Screening Assessment Substance Abuse Counseling/Education Crisis Intervention Treatment Planning Case Management/ Care Coordination Continuing Care/Aftercare/ Recovery Management Pharmacotherapy Drug Monitoring Detoxification Medical Care/ Primary Health Care Mental Health 1 Revised 5-8-07; reflects information from standards collected & reviewed as of April 30, 2007 WA WY MO MA CO GA ME OK OR AR CA DC NH NC NV SC AZ CT TN NJ TX VT FL WI State HI ID RI IL Trauma/Violence CLINICAL AND COMMUNITY SUPPORT SERVICES Life Skills Advocacy Family Programs/ Family Strengthening Parenting and Child Development Education Housing Supports & Assistance Educational/Vocational Remediation and Support Employment Readiness and Support Linkages with Child Welfare, Legal/ Criminal Justice Systems TANF Linkages Recovery Community Support Services (including Faith-Based Organization Support) Transportation Child Care Recreational Services 2
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The 2015 Clark County Fair is July 24 – 31.
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Last revised: Friday, 20 June 2008
This article contains general information only and is not intended to replace advice from a qualified health professional.


text: READ MORE July 6, 2015 "Tell Mama" Live Video Watch an electrifying performance of "Tell Mama" from TTB with Sharon Jones, and an interview/montage that will help you reach maximum excitement for this incredible tour. READ MORE June 21, 2015 Summer Soulstice Ticket Savings Today only, on Soulstice Day - the most soulful day of the year - we're happy to bring you some great savings on tickets to select Wheels of Soul Tour Dates. We have a limited number of pavilion tickets... READ MORE June 9, 2015 Hear the Wheels of Soul Spotify Session A few weeks back, members of TTB, Sharon Jones & the Dap-Kings and Doyle Bramhall II stopped by Spotify's New York City offices to perform a set for their Spotify Sessions series. We're pleased to share this session with... READ MORE May 18, 2015 2015 Beacon Run Announced A tradition continues this Fall with TTB announcing their annual run at the historic Beacon Theatre in New York City. This year, TTB will play four nights: September 25 with Los Lobos, September 26 with Charles Bradley & His... READ MORE April 28, 2015 TTB at SummerStage On May 18, TTB will kick off the 30th year of concerts at SummerStage in New York City with a free show in Central Park. There are no tickets for this show, it's entirely first come, first served, so... READ MORE April 16, 2015 Mad Dogs & Englishmen Tribute at Lockn' We're excited for a special night of soul music at LOCKN' Festival! Catch our tribute to Mad Dogs & Englishmen featuring Leon Russell, Dave Mason, Rita Coolidge, Chris Robinson, Doyle Bramhall II and more.


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January 13, 2012, Alan Berube
October 5, 2011, Martha Ross
September 9, 2011, Alan Berube and Jonathan Rothwell
February 22, 2010, Bruce Katz
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Thu December 27, 2012
Former PM Edward Seaga Heralds Jamaica's Music
By editor
Former prime minister and music producer, Edward Seaga, compiled an album to mark Jamaica's 50th anniversary of independence. It's called, Reggae Golden Jubilee: Origins of Jamaican Music. Host Michel Martin speaks to Mr. Seaga about what he sees as the 100 most significant songs to emerge from the country.


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"Whether students are starting kindergarten or entering college – communication is vital in the transition and planning. Shifting from summer to school is a time of jitters with anticipation of what is ahead," stated Dr. Nina Radcliff. "Refresh positive memories on the way for everyone involved and take time in this transition to enjoy new adventures and maintain a healthy balance amongst all the activities" she added.
About NINA RADCLIFF, MD:
Dr. Nina Radcliff is a practicing physician dedicated to helping people live healthier lives and gain wise understandings about health and wellness concerns facing our nation. A Board Certified Anesthesiologist and member of the American Society of Anesthesiologists where she serves on committees for Young Physicians and Communications, she an author and often called upon by national, regional, and local media to provide medical expertise on breaking medical news and topics impacting lives, today. In addition, she is a regular medical contributor for newspapers and magazines with health and wellness education: "Dr. Nina's What You Need to Know."
Read the full story at http://www.prweb.com/releases/2014/08/prweb12068111.htm.
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The group is building a multi-racial, cross-class movement that makes racial justice a sustained priority for Jews.
Author Tariq Ali analyzes Syriza's failure to stand up to the troika's demands and proposes a referendum that would place the issue of Greece's eurozone membership on the table.
Martha Sorren is a fellow at Truthout.


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1992 Chevrolet Astro 3dr Minivan
I have the 92 astro that me and everyone I work with the "ASTROID" this thing has been in the shop so many times after it hit 120K miles its not worth owning any more.The A/C went out, cruise, doesnt work, and the brakes are very sensitive. The brakes are horrible, when applying the brakes its like theres air bubbles in the brake lines because its not a smooth stop. The only good thing is the good gas mileage and the fine tuned stereo. It's had an oil change at 3,000miles and whenever it needs serviced.
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MIDDLEBURY — In the past 10 years, national security threats have come to be almost synonymous with terrorism.
But the security threats that top the list of Julie Smith of the University of Vermont Extension are of a different nature: They include foot and mouth disease, dangerous weather in livestock production centers, and anything that could disrupt U.S. agricultural systems.
MIDDLEBURY — When Middlebury College is in session, the school's radio station, WRMC 91.1-FM, experiences such high demand for radio shows from its student body that it can fill every hour of the week with original programming, and still must turn away aspiring DJs.
During the summer, the complexion of the station's weekly schedule looks — and sounds — considerably different.
SHOREHAM — The Fort Ticonderoga Ferry has finally started its 2011 season after a seven-week, flood-related delay that has taken a financial toll on the system's owners.
"Things seem to be going better right now," said Alison Matot, who co-owns the ferry with her husband, Michael. The historic cable-drawn ferry links Shoreham with Ticonderoga, N.Y., across Lake Champlain. Were this a "normal" year, the Matots would have been able to fire up the ferry back in late April.
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NEW HAVEN — The gymnasium in the New Haven Town Hall will be closed for energy efficiency renovations from July 5 until the start of the school year.
The Mary Johnson summer children's program that runs throughout the summer will not be interrupted, town officials said, but indoor basketball players will be forced to venture outdoors.
FERRISBURGH — Ferrisburgh selectmen and former town fire chief Bob Jenkins, still an active officer of the Ferrisburgh Volunteer Fire Department, recently decided to step down from the selectboard.
Jenkins' letter of resignation simply cites "personal reasons." On Thursday, he said he enjoyed many aspects of his service on the board, but preferred to devote his time and energy to the fire department.
"I can get back to my firefighting, and that's my life, anyway," Jenkins said.
VERGENNES — The Bixby Memorial Library board of trustees has chosen longtime Addison Independent advertising manager and Addison resident Jane Spencer to fill its newly created position of library director.
After 31 years at the Independent, 28 leading its advertising department, Spencer will officially assume her new job on Aug. 29, said Bixby board of trustees president Thelma "Kitty" Oxholm.
MIDDLEBURY — State and local health care administrators are studying the possibility of opening a methadone clinic in Middlebury, a plan that has some local officials concerned about the prospect of such a service producing a spike in drug-related crime in Addison County's shire town.
Methadone is a synthetic opioid, similar to morphine. It is used as pain reliever, but also as part of a treatment plan to reduce withdrawal symptoms in people addicted to heroin or other narcotic drugs.
Editor's note: This is another in an occasional series on Vermont in the Civil War.
MIDDLEBURY — In between dodging Rebel bullets and bayonets during the bloody Civil War battles of Spotsylvania, Cold Harbor, Petersburg and Cedar Creek, George Howe of Shoreham somehow found time to tenderly court the love of his life, Lorette Wolcott, through letters sent home.
BRISTOL — Decorate your outhouse, fire up the grill, whip out your flag and get ready for this year's Fourth of July celebrations.
A full slate of activities has been prepared at venues around the region, including concerts, parades and a singular competition in Bristol known as the outhouse races. Oh, and of course, there will be fireworks.
VERGENNES — About four dozen state, local and nonprofit officials on Monday morning joined Sen. Bernie Sanders (I-Vt.) on Armory Lane for the groundbreaking ceremony of a long-awaited and — according to all — much needed senior housing and meeting center.
The $5.8 million, 25,000-square-foot building next to American Legion Post 14 and the Shaw's Supermarket plaza will include a library and meeting and dining rooms. It will also host local senior lunches and provide a home for the area's Meals on Wheels program.
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