Appendix A

Develop joint cooperation among substance abuse agencies, schools, courts, probation officers, health and mental health providers, job training programs, and human service agencies. Create inventory of local, state, and federal resources available to the treatment program.

Establish an advisory board to assist the treatment program in collaborating with other resources and organizations, and to advocate on behalf of the program. This board should reflect the cultural and socioeconomic diversity of the women and include recovering persons as well as community leaders. Training and support are necessary.

Cross train staff in collaborating organizations to develop an integrated continuum of care for each woman in treatment and to address differences in philosophy, experience, and style of various disciplines.

Staffing should include individuals who are culturally competent and sensitive to and knowledgeable about treating substance-abusing women.

Substance abuse treatment in correctional facilities should be delivered by trained and certified personnel.

Staff training should encompass the guidelines generated in CSAT's TIPs that relate specifically to perinatal substance abuse.

Clinicians and program managers should participate in staff training. Such training should help lead to an understanding of the impact of psychological and psychiatric disorders, incest, physical and sexual abuse and their impact on recovery, and readiness for treatment, family dysfunction, multi-addiction, and the importance of flexible treatment approaches.

Admission priority must be given to women who are known to be pregnant, HIV-positive, or who have AIDS, and/or TB. Pregnant/postpartum women should be referred immediately for obstetrical care. (See TIPs.) Immediate referrals must be made if the program cannot provide appropriate care for these women. It is essential to document all referrals and admissions.

Assessments for possible pregnancy, HIV status, and exposure to and/or existence of TB should begin immediately.

Same-day intake services should be offered whenever possible.

Assessment may occur over a period of time. A complete health assessment must be conducted, and must include a physical examination, psychosocial evaluation (including psychiatric assessment where indicated), as well as an assessment of a woman's reproductive, oral, and nutritional health status.

Other assessments must include a substance abuse history; physical, emotional, and sexual abuse history (past and present); educational level and intellectual functioning; work history; family assessment; current living situation and childcare responsibilities; and racial/cultural/ethnic factors that are relevant to treatment. There should be an assessment of patient eligibility (and subsequent registration) for Medicaid, Medicare, SSI, public assistance, and other health and human service benefits.

An individualized treatment plan, including a plan for relapse prevention and continuing care, must be developed in collaboration with each woman entering treatment.

Medical assessments and subsequent care should be provided through arrangements with healthcare facilities accessible to individuals in the community or on-site, and should include the provision of preventive and primary medical care (including prenatal care, if appropriate); medical or medically supervised detoxification services, where clinically indicated; linkage to psychiatric care; provision of or established referral linkages as needed for acute medical care; testing and treatment for hepatitis, tuberculosis, HIV and HIV disease, sexually transmitted diseases, anemia and malnutrition, hypertension, diabetes, cancer, liver disorders, eating disorders, gynecological problems, dental and vision problems, and poor hygiene. It is preferable to have a healthcare professional available to consult directly with the program.

Women's Health Services. Preconceptional care should be provided either on-site or through referral, for nutrition, family planning, and general gynecological services.

Pharmacotherapy intervention should be provided on an as-needed basis and should include provision of, or established referral linkages, for concomitant assessment and monitoring by qualified medical or psychiatric staff. Interventions should promote equal access to treatment for all women based on assessment of their ability to participate in treatment.

Urine testing should be used where clinically appropriate, and should be conducted on an initial and random basis. (See TIPs.) The program should follow informed consent guidelines responsive to State reporting requirements, if applicable.

Infant and child health services should be provided either on-site or through referral and should include the following: primary and acute healthcare for infants and children, including immunizations, nutrition services (including assessment for WIC eligibility), and a developmental assessment by qualified personnel. For treatment programs without medical personnel on- site, a back-up medical plan that identifies a protocol for pediatric emergencies must be in place.

Early Intervention Services for children should be available. Access to an age-appropriate, comprehensive developmental assessment by qualified personnel, including an assessment of learning and developmental disabilities, should be provided to all children, beginning at birth. On-site provision of, or referral to, early intervention and remedial programs, and linkages with State Individuals with Disabilities Education Act (IDEA) should be encouraged.

Home-Based Support. Public health nursing and/or social work visits should be provided to high-risk postpartum women and their infants, especially to new mothers and those who are discharged within 24 hours after delivery. Linkages and referrals should be established with home care agencies.

Appropriate linkages to local, state, and federal programs must be maintained for those services not provided on-site.

Linkages with outreach, outpatient, and residential programs should be maintained as a means to assure appropriate matching of women to substance abuse treatment. Similarly, linkages with parental/child programs (e.g., Head Start) should be encouraged.

Support should be offered with the criminal justice system where appropriate, and should include intervention with juvenile or adult justice authorities, TASC (or related case management/tracking systems), Legal Aid, and/or Bureau of Indian Affairs. Access to needed legal services should be provided if not available through Legal Aid, probation, immigration, child welfare, foster care, and legal service.

Substance abuse education and counseling, psychological counseling (where appropriate), and other therapeutic activities should be provided by practitioners who are licensed or certified to provide these services and matched in competency to the populations served.

Services should be offered in the context of families and relationships, including individual/group/family therapy. Counseling for partners and fathers of babies should be promoted/provided at critical times throughout treatment.

Counseling should address low self-esteem; race and ethnicity issues; gender-specific issues; family relationships; attachment to unhealthy interpersonal relationships; interpersonal violence, including incest, rape, and other abuse; eating disorders; sexuality; parenting issues; grief related to loss of alcohol and other drugs, children, family, partner, work, and appearance; creating a support system that may or may not include family and/or partner; developing a vision for the future and creating a life plan; and therapeutic recreational activities for women alone and with their children.

Parenting Education. Counseling, including information on child development, child safety, injury prevention, and child abuse prevention should be provided. Parenting education should be integrated with substance abuse counseling in order to be recovery-oriented. A woman's family issues that affect parenting should be addressed in a way that supports rather than compromises her stage of recovery.

Relapse prevention should be a discrete component or phase of each woman's recovery plan.

Flexibility and creativity should be stressed in the use and timing of therapeutic approaches. Accusatory, judgmental, and humiliation techniques are inappropriate and have not been proven to be effective.

Educational training and remediation services should be provided, with on-site provision of or case-managed referrals to local education/GED programs and other remediation issues identified at intake.

English language competency and literacy assessment programs should be facilitated.

Job counseling and training should be provided, if possible, via case managed/coordinated linkages to community programs.

Provision should be made for graduate re-admission to more intensive forms of therapy in cases where relapse has occurred.

As women complete the intensive phase of treatment and move into the community, the effects of domestic violence, rape, and childhood sexual abuse must continue to be addressed.

Socioeconomic issues (e.g., jobs/educational deficits) require long-term remedies and must be included in relapse prevention planning.

Public assistance and housing must be addressed in the continuing care plan.

Ongoing transportation assistance must be provided for attendance at self help groups (AA, NA, and other support meetings).

Continuing provision of primary healthcare services and medical assistance as needed for women and children.