In 2001, a nonprofit drug treatment provider called Bridges joined a bold new venture with the Sacramento County Department of Health and Human Services (DHHS). It was aimed at better serving the children of parents who had come into contact with the child welfare system because of drug use or addiction.
The resulting Specialized Treatment and Recovery Services (STARS) program would sit at the center of the county’s family drug court, developed to help address Sacramento’s dismal reunification rates, fueled in part by parental drug use. The program would route treatment decisions and case management for those parents through a nonprofit staff. And that staff would mostly comprise former addicts.
STARS remains at the center of Sacramento’s family drug court, which handles between 500 and 600 parents each year – hundreds more than most drug courts in the country. With STARS in the middle, the court has produced results, more than doubling the rate at which children in Sacramento’s foster care system are reunified with parents.
At a time when drug-related removals are fueling a nationwide surge in foster care, it is one of a handful of ventures other child welfare systems should be taking note of. The program was recently featured at a federal policy briefing about strategies to serve families struggling with addiction.
“It made a 180 degree change in the way we did our work and the success we saw,” said Lucy Tosti, a Sacramento social worker who retired last year after four decades on the job. “In the course of my career, it was the most impactful change on the system.”
Origins
In the 1990s, Sacramento’s child welfare system was handling parents with substance abuse issues, as many systems do today. They were assigned a caseworker, referred for treatment and that was about it.
“Social workers would try to get [parents] into programs and call all over town each time,” Tosti said. Long stays on a wait lists for treatment were a common occurrence.
Former DHHS Director Bob Caulk secured some foundation funding to start a training program to help county social workers better understand substance abuse issues. Every frontline worker was required to go through a “substance abuse disorder 101” class.
“Current treatment services meet less than a fourth of the demand, and about 800 people are on the waiting lists for treatment,” Caulk told The Sacramento Bee in 1994. “The system is saturated. The best thing you can do about drug and alcohol abuse is treat it. We might as well train our labor force to deal with it.”
Caulk brought in a former DHHS union leader, Toni Moore, to help build the training program. But workers chafed at the extra workload – carry cases and now help treat addiction – heaped upon them at a time when their caseload was already tough.
In 2000, the county built a family drug court, using the blueprint from an existing court program in San Diego. It would be called the Drug Dependency Court (DDC).
Nonprofit organization Bridges was tapped to develop Specialized Treatment and Recovery Services, a program that would contract with DHHS to manage the cases of parents referred to the new court.
Durbin said that there was some initial concern about the fact that many of the specialists on the STARS staff are either recovering addicts, people whose families were affected by drug and alcohol dependency, or both. And they would be responsible for reporting on other addicts’ failure to make required meetings or pass drug tests.
“There’s a fear that somehow, we’d be telling the social worker it wasn’t happening,” said John Durbin, the testing and training coordinator for Bridges. “Nothing could be further from truth. They are being monitored by someone who knows better.”
How it Works
Each parent referred to the DDC is assigned a recovery management specialist employed by STARS. The program is located across the street from the court, and it is every parent’s first stop after the initial hearing.
Sacramento County Dependency Drug Court Model. Source: Sacramento County Department of Health and Human Services
Durbin said the program has conducted more than 10,000 intakes since STARS began. Roughly two-thirds of the participants are women, he said.
The specialist will be in charge of the following during the parent’s time as a DDC participant:
- Twice-monthly meetings with the participant, half of which must take place in their home or in the community
- Determining and then accessing treatment options in the community for the participant
- Random drug screenings
- Leading case conferences with the participant and caseworkers
“The specialist is kind of like their coach and advocate, and the eyes/ears of court,” said Dana Martinez, DDC coordinator for Bridges.
Tosti said when STARS entered the picture, the effects were quickly noticeable.
“They produced immediate drug results instead of a lag time,” she said, and parents were placed into treatment faster because the program specialists were much more on top of program availability.
“It’s vastly better than it was before we had them,” said Hana Belfour, the managing attorney for Parent Advocates of Sacramento, who has represented parents in dependency cases for 17 years. “It is so much better than the crap that was available prior to there being STARS.”
STARS clients served per year. Source: Sacramento County Department of Health and Human Services
For the first six years of the program, STARS specialists were only placed in charge of cases where the children were removed from the home. In 2007, the county added an in-home, early intervention program to complement DDC.
STARS now case manages that in-home program as well, with a significant caveat: for clients whose children are still home, the organization is required to have a caseworker on the phone within 15 minutes if it’s discovered that the parent has failed a drug test.
“Not leave a message; on the phone,” Durbin said. STARS and county staff will then confer to figure out a course of action.
STARS received 3,343 clients between 2012 and 2016, according to the county, an average of 669 per year.
All of the STARS specialists are counselors certified by the California Consortium of Addiction Programs and Professionals. The budget for the program is $2 million, according to Durbin, which he said amounts to about $5,000 per client in an average year.
The program was initially funded with a blend of federal grants and the state’s tobacco settlement money. It has now been established in the county’s own budget, Durbin said.
Number of Children Entering Sacramento County Family Drug Court Programs. Source: Sacramento County Family Drug Court 2014-2015 Annual Evaluation Report
Results
The success or failure of STARS is inextricably linked to the success of the entire Dependency Drug Court. It is a central component of a system that relies on the court, the social workers and the drug treatment program. So the outcomes of the parents on the DDC docket is, by default, the measure of STARS’ success.
Children and Family Futures (CFF) is contracted by Sacramento County to periodically evaluate the family drug courts. CFF uses a set of comparison groups to gauge the impact of the DDC and the early intervention courts, both of which use STARS specialists. The DDC court participants were compared with a smaller group of parents who had been referred to DDC, but never participated.
Nearly 54 percent of the children of DDC clients were reunified within 12 months, according to the most recent evaluation covering 2014-2015. Just 19 percent of the children of parents in the comparison group were reunified.
The DDC group posted a significantly higher rate of re-entry into foster care than the comparison group; 14.9 percent, compared with 3.1 percent. CCF’s evaluation suggests that the comparison group’s low rate of re-entry “is likely due to the small portion of children who reunified within 12 months of the program start date.”
Regular contact with the STARS recovery specialist is one of the five compliance measures for DDC participation. A 2015 study by CFF found that compliance with that measure and three others (drug tests, support groups and treatment participation) “closely align with improved child welfare outcomes,” namely reunification rates.
The early intervention program was compared with a group of parents who would have been eligible had the program existed before 2007. The findings:
- After 12 months, 73 percent of the kids of participants remained in the home. In the comparison group, it was 59.6 percent.
- The reoccurrence of maltreatment rate after 12 months was 4.3 percent for the early intervention group, less than half the rate of the comparison group (9.1 percent).
DDC Permanency Outcomes 12 Months Post Project Start. Source: Sacramento County Family Drug Court 2014-2015 Annual Evaluation Report
Tosti, the former Sacramento caseworker, identified two reasons why STARS was an integral part of achieving those numbers. The first is that it supplants the notion that caseworkers are, by themselves, able to closely monitor and assist in the progress of drug-addicted parents.
“In the life of social workers, addressing parent drug use is one-one-hundredth of your day,” said Tosti. “You have 30 or 40 kids, some out of state, then you have therapists’ visits and court reports to write. The drug use piece is a huge piece, but a small piece of what we need to deal with as social workers. Effectiveness in drug treatment, it’s very complex, it’s intense.”
The other reason, Tosti said, is that the STARS staff are able to use their own experience with addiction to two ends: better traction with clients, and a better ability to sense problematic situations.
“I remember we had this one mom, they thought she had been cheating on her 12-step meetings,” Tosti said. “STARS had brought that to our attention, and she denied it to me. We busted her the next month submitting fraudulent slips. They caught it early.”
Durbin said the credibility of the specialists is the reason it has been successful.
“When someone comes across the street, hurting from court, a guy like me can empathize, and their shoulders just drop in relief because it’s not us against them,” Durbin said. “They kind of open up and relax. We help re-establish their integrity.”
Belfour said STARS’ impact has been somewhat compromised in recent years by a change in its initial protocol, possibly due to the shift in funding sources.
“At its best point, [STARS] would meet with parents after the first hearing,” Belfour said. “It was in the courthouse, they’d interview them, and get them set up with treatment that day. No waiting.”
Now, she said “they set them for appointment to come back in about a week, and that all drags out. The more time people have to escape, the more they do, so some go home and use. The immediacy stuff has been whittled down.”
The tobacco settlement funds could be used to prioritize drug court clients in the treatment pecking order in a way that the county money isn’t, Belfour said. She also said the delays at the front end of STARS might be partially attributable to a combination of more clients, and more county control.
“A little bit of is that we kind of decided to send every parent we possibly can” to drug court, she said.
EIFDC Children Remaining at Home. Source: Sacramento County Family Drug Court 2014-2015 Annual Evaluation Report
Expanding STARS
So far, the STARS model has only been adapted elsewhere once. The Connecticut Department of Children and Families has drawn from it for a statewide venture that will not use a drug court model, but will ramp up case monitoring for substance-abusing parents.
CFF has presented on the STARS model at several national and regional conferences in the past decade. And last year, as the Family First Prevention Services Act was discussed in Washington, D.C., proponents of the bill featured STARS at a Capitol Hill policy briefing about working with addicted parents in the system.
At present, the STARS program lacks evidence of its individual effectiveness on the system. STARS is a component of a drug court that has demonstrated success, but there has been no study to gauge how much of that success might be attributable to STARS.
The California Evidence-Based Clearinghouse currently classifies the program as “Not Able to Be Rated,” meaning it lacks any “published, peer-reviewed study utilizing some form of control (e.g., untreated group, placebo group, matched wait list study) that has established the practice’s benefit over the placebo.”
Tosti, who now trains new child welfare staff through the Northern California Training Academy at the University of California, Davis, said she hopes more systems learn about and adopt it.
“STARS should be the norm across the board,” Tosti said. “It has been a real gift to our kids and families.”
