Improving Vermont’s Adult Mental Health System: Where we have Been,

where should we be going?September 10, 2014

Killington Grand HotelKevin Huckshorn PhD, RN, MSN

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Current Trends and Best Practicesin Mental Health Settings

Introduction2

Thanks for inviting me to speak to you today.

I know that VT has been thru a lot of change recently.

I am going to talk today about some of the trends and best practices going on in the US as these relate to recovery oriented systems of care that are trauma informed, evidence-based and have quality outcomes.

I want to start with a story.

Outline3

1. The Americans with Disabilities Act and the Olmstead Decision: What it means & how implementation looks in practice.2. Peer Inclusion in MH Services: What does that look like?

Outline4

3. The Building Bridges Initiative: New practices important for adult systems to know and support in their states.

4. Early Detection, Intervention, and Prevention of Psychosis EBP.

Olmstead Community of PracticeKevin Huckshorn PhD, RN, MSN

DSAMH Director

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USDOJ Settlement Agreement

The Delaware Experience

DE and the USDOJ SettlementThe Settlement Agreement between the State and the

U.S. Department of Justice shifted the focus from the state hospital to the community and ADA/Olmstead Act.

More importantly, this agreement became the blueprint for how Delaware would provide mental health services to individuals with severe and persistent mental illness, statewide.

Even more significant is this factor. The ADA and Olmstead Decision identified early what is required by all states when serving people with disabilities. Whether USDOJ is “in” your state, or not, you need to measure your progress by ADA.

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Delaware’s Olmstead Settlement Agreement Mandate(s)

Similar to other involved states

Delaware’s Olmstead Settlement Agreement Mandate(s)

Similar to other involved states

The State of Delaware must make systemic changes that ensure that individuals with ADA covered disabilities, including those in recovery from mental illness and substance abuse receive care: in the most integrated setting (meaning, not

separate from the community in which he or she is a resident), and

in the least restrictive setting (meaning, care is provided with as few limitations as possible, e.g., community based as opposed to treatment that requires living in a treatment facility)

The State of Delaware must make systemic changes that ensure that individuals with ADA covered disabilities, including those in recovery from mental illness and substance abuse receive care: in the most integrated setting (meaning, not

separate from the community in which he or she is a resident), and

in the least restrictive setting (meaning, care is provided with as few limitations as possible, e.g., community based as opposed to treatment that requires living in a treatment facility)

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DE’s USDOJ Mandate reframed

One of Delaware’s first steps were to reframe the Settlement Agreement into clear goals. These goals were as follows (and are universal for ADA/MH):1.To develop, implement and monitor a process to discharge all individuals living in an institution, back to their chosen community in an integrated setting of their choice. Not an issue in VT?2.To re-organize the DE Behavioral Health Crisis Response System to focus on preventing crises and unnecessary inpatient admissions, when possible.

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DE/DSAMH History with USDOJ9

The USDOJ came to DE in 2008 following over 100+ DE News Journal articles about serious problems at the Delaware Psychiatric Center (the single state hospital).

They found a state facility with over 100 clients that no longer met inpatient criteria; overuse of seclusion, restraint & involuntary medication; events of client abuse and neglect; and a lack of active treatment or choices in housing.

To list some findings…

DE USDOJ TargetsData Trends and Status Report10

This new focus on community services made us regroup in terms of the populations we serve. Regarding the USDOJ Target Population (in DE), we currently have 11,000 persons in the target population (persons with SPMI who are at high risk for institutionalization) (DE POP is 900,000+).

Peer support, integrated housing, supported employment leading to work, and “voice and choice” are as important as hospital issues for ADA.

Supportive EmploymentFY12-FY14 (through May)

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Supportive HousingFY11-FY14 (through May)

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Inpatient Bed Day UtilizationFY11-FY14 (through May)

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Peer Contacts FY13-14

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MCIS Average Call Response Time ReportFY14

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RRC & CAPES (24 hr assessment centers) and Mobile Crisis Hospital Diversion Rates

-16

Provider Staff and Law Enforcement Trained

on Diversion Practices FY 13-1417

Crisis Apartment Bed Day UtilizationFY 13-1418

Implementing the ADALessons Learned

19Implementing the community implications of the

ADA requires the highest level of state leadership to buy-in on this work, for the long term. It requires an ability to see what can be” and not “what is.”

This is necessary work, for all states to move toward.

Getting your community MH stakeholder’s on board is critical. Takes a lot of communication.

Developing a manageable plan with support from the Gov Office and your legislature is also critical.

Housing issues are generally very complicated and, if you do not have that expertize, hire it.

Implementing the ADALessons Learned20

For Vermont, specifically with regards to the ADA:You have already started to do work on reducing SR and forced medications and you are to be congratulated for this. ROSC that are “trauma informed” do not use SR or forced meds except as the very last resort. You may need to evaluate your policies on full participation in treatment and discharge planning, by clients in care, as this process is core to ADA. Community re-integration into “normal living arrangements (one adult=one apt or home) is also keyAs is the integrated use of Peer Support staff.

Peer Support… What makes us Unique!

Gayle Bluebird, RNDirector, Peer Services

Mental Health Association, MHAKevin Huckshorn Ph.D

Delaware Substance Abuse and Mental Heath, DSAMH

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Artwork by:Knicoma Frederick

Creative Arts Factory

Peer Support Information for VT22

This work is going on all over the countryIs still a pretty new model and subject to all

kinds of interpretations and definitionsThe integration of Peer Support is also the most

powerful tool I have seen in three decadesThese people/staff innately understand “how to

engage”; how to share “what recovery is”; and are inclusive and always respectful

Here are some lessons learned about Peer Support

The Power of Peer Support

Peer Support is not like clinical support nor is it just about being friends.

Peer Support helps people to understand each other because they’ve been there, shared similar experiences and can model for each other a willingness to grow.

(Mead & MacNeil, 2003)

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Where We Are Now in DEOr, what can be done in 4 years

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•14 Peer Trauma Grant Specialists in Community and Substance Abuse Agencies.• Delaware Community Resource Coalition (DCRC) in place with a Director. Our statewide Peer Network. • Five Peer-Operated DE Recovery and Resource Centers (RVRC, ACE, Hopes & Dreams, Open Door, Creative Vision) • Common Ground Program implemented (EBP)• Peers hired in the community for ACT teams, and Community agencies.• 16 Peer Specialists working, as staff, at the state hospital•Mental Health Court Peer Team developed (most recent).•Over 160+ Peer staff now employed. Was “1” in 2009.

Peer Certification Training

• Peers designed the training curriculum for certification

• The Emphasis was on creativity• All Peers must currently be

working to be trained• Consists of 72 hours• To be certified with the State

Certification Board• Also developed Peer Support

101 Training for Peers and Providers.

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1st Peer Certification Training

Peers are Unique Because they…

• Provide transitional services from hospital to community• Can provide Medicaid reimbursable services on ACT

teams (January, 2015)• Provide individual support to frequent users of service.• Use prevention tools to help individuals avoid crisis, in

and out of hospitals.

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Peers Are Unique Because…

• We dress casually.• We talk naturally.• We share handshakes and

hugs.• We “tell our stories.”• We do not use jargon• We do not have rigid rules

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Dara HagansInpatient Peer Specialist

Peers Are Unique Because…

• We prioritize finding out about a person's interests and strengths so that he/she can use their own individualized approaches to healing including alternative methods.

• This work teaches “illness management” in a normative manner.

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Peers Are Unique Because…

We use a person’s full name whenever possible and with his/her consent.

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HIPPA laws are meant to protect confidentiality but often have an opposite effect. People often begin to think of themselves as

non-persons. The key is to ask; the purpose is to honor.

Peers Are Unique Because…

We introduce wellness techniques creatively and YOU could also!

 

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Examples:•Engagement•Employment•Searching on Internet for services•Healthy Snacks •Walking/exercise•Affirmation•Drop Zone “DIC Resource Center”•Creative Arts Projects•Restaurant Outings•Hands and Heart Project

Peers Emphasize Arts and Creativity:

Examples:• “Creative Arts Factory”- Peer-Run Arts Center.• Art Exhibits• Drumming Circle• Note card Project• Arts Carnivals• Decorating Comfort Rooms• Special Outings

31“Henrietta”

Peers Deliver Hope Totes

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Admission Comfort Bags:

•Given to all Clients on admission.•Contains rights information •Client Handbook• Peer Support information•Peers orient new clients being admitted which can be a stressful time“All items selected with safety in mind.”

Creative Vision FactoryA Peer Run Arts Program33

RVSC is a DIC that provides MH and PC (with UD APRNS); a 24/7 homeless shelter; homeless services; full kitchen; laundry; and events all year long. First

Health Home!34

Peer Developed Trauma Booklet

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•Created in 2011•Written, and designed by Peer Support staff•In easy-to-understand language.•Illustrated with national artists’ artwork.•Designed for persons receiving services… and others•Describes what being a victim of trauma is about and how to understand this experience. •And how to get help.

“Hugging Form”Meghan Caughey

The Building Bridges Initiative (BBI):Advancing Partnerships. Improving Lives.Building Bridges Initiative represents a huge change in approach to children and families in child MH programs.

This information is important for adult systems of care as we get these referrals into our adult systems and we can start to provide “early interventions” to reduce this.

Developed by Beth CaldwellDirector of the Building Bridges Initiative

Presented by Kevin Huckshorn with BBI approvalSeptember 10, 2014

BBI Mission

1. To identify and promote practice and policy initiatives that create strong and closely coordinated partnerships and collaborations between families, youth, community- and residentially-based service providers, advocates and policy makers.

2. To ensure that comprehensive services and supports are family-driven, youth-guided, strength-based, culturally and linguistically competent, individualized, evidence and practice-informed, and consistent with the research on sustained positive outcomes.

Emerging research on residential effectiveness, for example:Recidivism/Readmissions

• 68% of all youth discharged from out-of-home programs in one state (2009) were back in out-of-home care within 1 year -for all licensed residential programs VA. Damar Services, IN (BBI implementer) with ranges from 3-11% each year for 5 years post discharge (including hospitalizations

Some of the Critical Issues

Critical elements

Residential-specific research shows improved outcomes with: shorter lengths of stay, increased family involvement, and stability and support in the post-residential

environment (Walters & Petr, 2008).

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Why is BBI important to Adult MH Systems?

Effective “Prevention and Early Interventions” could prevent youth from entering the adult MH system of care

We all need to work together, in our state systems, to change from what we have always done to “what works” by evidenced outcomes!

Why is BBI important to Adult MH Systems?

Currently, and historically, troubled kids go into residential services, often from months to years.

Current evidence is that these services do not work for these kids. Not in terms of learning new skills or being successful once discharged.

Neither does expecting that children will “willingly separate” from their families, no matter how dysfunctional.

Most of these children end up right back in residential, in Juvenile Justice, in adult jails or in adult MH systems of care.

Why is BBI important to Adult MH Systems?

What BBI now knows is that kids need individualized activities that keep them in the community, in school, and or work (for older youth).

Residential Services should be short term and used to re-integrate into community life.

Community services should focus on life skills, illness management, and hopes/dreams.

And family re-unification services are critical even if they are delayed till youth are almost adults.

Preventing Psychotic Disorders by Early Detection and Intervention

William R. McFarlane, M.D. Maine Medical Center Research Institute

Portland, MaineUSA

Tufts UniversityUniversity of Vermont

Kevin Ann Huckshorn(partial Presentation with PIER approval)

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Early detection and prevention in another illness

“If you catch cancer at Stage 1 or 2, almost everybody lives. If you catch it at Stage 3 or 4, almost everybody dies.

We know from cervical cancer that by screening you can reduce cancer up to 70 percent. We’re just not spending enough of our resources working to find markers for early detection.”

---Lee Hartwell, MDNobel Laureate, Medicine

President and Director, Hutchinson Center

New York Times MagazineDecember 4, 2005, p. 56

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Early detection and prevention in psychotic illness

“The psychiatrist sees too many end states and deals professionally with too few of the pre-psychotic.”

--Harry Stack Sullivan, 1927

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Shortened productive lives

Source: Mental Health Report of the Surgeon General

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$10 million

Lifetime costs for each new case of schizophrenia

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25%

Proportion of hospital beds occupied by, and disability payments to, people with severe mental

disorders

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75%

Proportion of people who have one psychotic episode and schizophrenia and then develop

disability

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10%

Proportion of people with schizophrenia who are gainfully employed

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2-3%

Proportion of youth who develop schizophrenia or a severe, psychotic mood disorder

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12-15%

Proportion of people with schizophrenia or a psychotic mood disorder who commit suicide

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Years of life lost by people with schizophrenia due to all causes, including

heart disease, cancer and suicide

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Functioning as an effect of number of psychotic episodes

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Effects of untreated initial psychosis

Becoming psychotic is a personal trauma and the longer it lasts, the

more it can become harmful and stigmatizing.

Being psychotic reduces cognitive and social function. People may

lose contact with family and friends, fail school, or drop out of

work.

Neurobiological deficit processes, linked to symptom formation,

may possibly proceed unlimited as long as the patient is untreated.

The longer the psychosis lasts, the more difficult it may be for the

therapist to establish a good therapeutic relationship with the

patient.

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CognitiveDeficits

Affective Sx: Depression

Social Isolation

School Failure

Biological Vulnerability: CASIS

Brain Abnormalities

StructuralBiochemical Functional

Disability

Social and Environmental

Triggers

Incr

easin

g Posi

tive

sym

ptom

s

Early Insults

e.g. Disease Genes, Possibly Viral Infections, Environmental Toxins

After Cornblatt, et al., 2005

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Biosocial theory

Major psychiatric disorders are determined by the continual interaction of specific biological dysfunctions and specific social

phenomena

Psychological factors determine course at the case level by influencing biological and social forces

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SOCIAL RISK FACTORS Expressed emotion (families, teachers, peers, helpers)

Critical commentsHostilityOver-involvementDecreased Warmth

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Is early intervention indicated in prevention of psychotic disorders?

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Trials of Indicated PreventionBuckingham, UKOPUS, DenmarkPIER, MaineEDIPPP, USAGRN, GermanyPACE I, II, AustraliaEDIE I, II, III, UKAddington, CanadaPRIME, North AmericaOmega-3 FAs, Austria

Family psychoeducation

Cognitive therapy

Biological treatment

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Early intervention is preventionOne year rates for conversion to psychosis

22.9%

7.6%

0

10

20

30

40Controls Experimental

%

23.0%

Fusar-Poli, et al, JAMA Psychiatry, 2013

Risk reduction = 66%

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Portland Identification and Early Referral(PIER)

Reducing the incidence of major psychotic disorders in a defined

population, by early detection and treatment:

Indicated prevention

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Professional and Public Education

• Reducing stigma

• Information about modern concepts of psychotic disorders

• Increasing understanding of early stages of mental illness and prodromal symptoms

• How to get consultation, specialized assessments and treatment quickly

• Ongoing inter-professional collaboration

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Family practitioners

Pediatricians

General Public

Mental health clinicians

Military bases and recruiters

Clergy

Emergency and crisis services

College health

services

PIER Team

Advertising

School teachers, guidance

counselors, nurses, social

workersEmployers

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Assessing Risk for Psychosis

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Psychosis Occurs on a Spectrum

Grandiosity

Suspiciousness

Auditory Hallucinations

Youth enjoys basketball and expects to attend college on a full

scholarship.

Youth is heading to New York City because he believes he is talented enough to join the Nicks.

Young woman goes to the mall and feels like people

are looking at her.

She refuses to go to the mall because she is certain that a specific person is out to harm her

Hearing indistinct buzzing or whispering

Hearing a voice clearly outside your head saying, “You’re a loser” or “You’re a failure.”

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Signs of prodromal psychosisSchedule of Prodromal Syndrome (SOPS), McGlashan, et al

A clustering of the following:1. Changes in behavior, thoughts and emotions, with

preservation of insight, such as:

Heightened perceptual sensitivityTo light, noise, touch, interpersonal distance

Magical thinkingDerealization, depersonalization, grandiose ideas, child-like

logicUnusual perceptual experiences

“Presence”, imaginary friends, fleeting apparitions, odd soundsUnusual fears

Avoidance of bodily harm, fear of assault (cf. social phobia)Disorganized or digressive speech

Receptive and expressive aphasiaUncharacteristic, peculiar behavior

Satanic preoccupations, unpredictability, bizarre appearanceReduced emotional or social responsiveness

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Signs of prodromal psychosis

2. Significant deterioration in functioning Unexplained decrease in work or school performance Decreased concentration and motivation Decrease in personal hygiene Decrease in the ability to cope with life events and stressors

3. Social withdrawal Loss of interest in friends, extracurricular sports/hobbies Increasing sense of disconnection, alienation Family alienation, resentment, increasing hostility, paranoia

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Other criteria

Ages 12-35

Brief psychotic episode (< 1 month)

Genetic risk and recent deterioration (>30% GAF decrease) in youth (first (or second?) degree relative with a psychotic disorder)

Schizotypal personality disorder, age <20, combined with recent deterioration (>30% GAF decrease) are also at risk.

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Components of first episode psychosis services: Both evidence level A and rated as essential by international experts

Domain names and Components with level of supporting evidence (A-D)

Semi-InterquartileRange (0.0 - 0.5)

Selection of Antipsychotic Medication (Level of evidence: A)

.5

Clozapine for Treatment-Resistance (Level of evidence: A).

.5

Use of Single Antipsychotics (Level of evidence: A) .5

Psychoeducational Multifamily Group Psychoeducation(MFG) (Level of evidence: A)

.5

Supported Employment (Level of evidence: A) .37

.

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Family-aided Assertive Community Treatment (FACT):

Clinical and Functional intervention

• Rapid, crisis-oriented initiation of treatment

• Psycho-educational multifamily groups

• Case management using key Assertive Community

Treatment methods

– Integrated, multidisciplinary team; outreach PRN;

rapid response; continuous case review

• Supported employment and education

– Collaboration with schools, colleges and employers

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Family-aided Assertive Community Treatment (FACT):

Clinical and Functional interventions• Cognitive assessments used in school or job

• Low-dose atypical antipsychotic medication

– aripiprazole 5-20 mg, quetiapine 300-600 mg,

olanzapine 2.5-7.5 mg, risperidone 0.25-3 mg

• Mood stabilizers, as indicated by symptoms:

– Mood stabilizing drugs: lamotrigine 50-150 mg,

valproate 500-1500mg, lithium by blood level

• SSRIs, with caution, especially with aripiprazole

and/or a family history of manic episodes

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Key clinical strategies in family intervention specific to prodromal psychosis

Strengthening relationships and creating an optimal, protective home environment: Reducing intensity, anxiety and over-involvement Preventing onset of negativity and criticism Adjusting expectations and performance demands Minimizing internal family stressors

Marital stress Sibling hostility Confusion and disagreement

Buffering external stressors Academic and employment stress Social rejection at school or work Cultural taboos Entertainment stress Romantic and sexual complications

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ConclusionsCommunity-wide education is feasible in now 10 US cities.

Referrals were 30%, up to 60%, of the at-risk population.

Global outcome in FACT was better than regular treatment.

Average functioning was in the normal range by 24 months.<80% were in school or working at 2 years. ¾ were in school or working up to 10 years later. Five cities show a declining incidence.Four county-wide California programs are replicating. PIER Project saw a 66% reduction in conversion to potential

psychosis

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In SummaryI apologize for presenting all this information in such a short

time frame. If you want more information, email works.All of these initiatives are very important to you/us, in 2014

What the ADA and Olmstead really means at the ground level (regardless if you have a lawsuit).

The Power of Peer Support The need to change our approach to kids and youth in under 18 MH

service systems The real opportunity to prevent psychosis that now is evidence-based

This means a lot of work for you and yours. But the hope for better outcomes, provided by these

initiatives is terribly significant. I hope you take this on…76

Vermont Specifics

I really get the trauma your entire system has been under since “the Storm.” I also lived through this in FL after Andrew. For 4 months in south Dade County, living on cot,s and trying to replace 3 CMHCs that were wiped out.

From what I know you have been true “Vermonters…” You are strong and resilient and this fact is widely known.

I have asked David Mitchell to come up and talk for 10 minutes about his experience in implementing a Recovery Oriented System of Care, with a specific focus on reducing restraint and seclusion in his facility.

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“The future depends on what you do today.”

― Mahatma Gandhi

And you are the FUTURE of your state’s mental health system and the future of the client’s you serve. I just challenge you to act accordingly.

Cause if you don’t, no one will. KAH

Contact Information

Kevin Ann Huckshorn Ph.D, MSN, RN

Director: Division of Substance Abuse and Mental Health

Kevin.Huckshorn@state.de.us

302-255-9398 (office)*** Can put you in touch with Dr. McFarlane in ME

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BBI References and Websites If you want more information

Comprehensive State initiatives: 1) CA – initially 4 regions; 2) DE – modeling after MA, IN, MA –rebid every CW/MH licensed residential contract against BBI principles; 3) NH – initially 6 residential programs, 4) WA

Initial State level activities (AZ, FL, GA, LA, NM, OK, SC & WV; in CA (statewide) & MD – Provider associations leading)

County/City level initiatives (City: NYC; Counties: Monroe/ Westchester, NY & Maricopa, AZ)

Many individual residential and community programs across the country

Examples of Where BBI is happening? If you want more information

Comprehensive State initiatives: 1) CA – initially 4 regions; 2) DE – modeling after MA, IN, MA –rebid every CW/MH licensed residential contract against BBI principles; 3) NH – initially 6 residential programs, 4) WA

Initial State level activities (AZ, FL, GA, LA, NM, OK, SC & WV; in CA (statewide) & MD – Provider associations leading)

County/City level initiatives (City: NYC; Counties: Monroe/ Westchester, NY & Maricopa, AZ)

Many individual residential and community programs across the country

BBI Products & ResourcesBBI website (www.buildingbridges4youth.org): Please visit the

website and review all of the BBI documents available to support work with children, youth and families.

BBI Self-Assessment Tool (SAT) and the SAT Glossary: Residential programs, the youth and families they serve, and their community program counterparts now have a useful tool available to assess their current activities against best practices consistent with the BBI JR Principles. The SAT: designed to be used with groups of residential and

community staff, advocates, families and youth to facilitate discussion on how program and community efforts to implement best practices can be most effectively supported.

The SAT Glossary provides a definition of terms used throughout the SAT.

Will be available on the BBI website with additional information about how to use the SAT.

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BBI Products & ResourcesFamily Tip Sheets - Short and Long Versions: The BBI

Family Advisory Network, comprised of family members and advocates who have had children in out-of-home care programs, have developed both short and long versions of the Family Tip Sheet.

The Family Tip Sheets support family members by identifying important issues that family members might consider relative to their child’s residential experience and information they may want to explore with their residential provider.

It is recommended that both versions be distributed to family support/advocacy organizations; residential and community programs should also provide new and existing family members with copies of both documents.

State and county policy makers and associations may want to distribute both versions of the Family Tip Sheet to programs they oversee or to their member organizations.

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BBI Products & Resources Youth Tip Sheets - Short and Long Versions: The BBI Youth Advisory

Group has completed both short and long versions of the Youth Tip Sheet, entitled: Your Life – Your Future: Inside Info on Residential Programs from Youth Who Have Been There. The Youth Tip Sheets offer both words of support and a framework for guiding youth to ask questions that will help them be informed partners in their own care. Both the short and long versions of the Youth Tip Sheets can also be used as part of an admission packet. The Youth Tip Sheet – Short Version is for youth who may be

considering a residential program and/or those about to enter or who are already in a residential program. Ideally, a youth advocate or youth mentor would review the Youth Tip Sheet with the youth individually.

The Youth Tip Sheet – Long Version will interest youth who wish to gain a more in-depth understanding of how they can ‘take charge’ of their own treatment and recovery and can be used by advocates, providers, families and policy makers to ensure that residential and community programs serving youth, and their families, are truly youth-guided.

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BBI Products & Resources• Recently Developed BBI Documents available on BBI

website: BBI Fact Sheet on Child Welfare; Fiscal Strategies that Support the Building Bridges Initiative Principles; Cultural and Linguistic Competence Guidelines for Residential Programs; Engage Us: A Guide Written by Families for Residential Providers; Promoting Youth Engagement in Residential Settings

BBI Calendars of Events: Over the past five years many national associations and organizations have highlighted different aspects of the BBI in conference keynote addresses, half- and full-day pre-Institute events and conference presentations.

Articles about BBI: National publications have featured articles about BBI in their publications. Recent publications included the National Council for Community Behavioral Health, the national Teaching-Family AssociationTeaching-Family Association, and the special issue of Child Welfare on residential care and treatment, the journal of the Child Welfare League of America.

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• Documents & articles to support field (including system of care communities), e.g.:▫ Fiscal Strategies that Support the Building Bridges Initiative

Principles▫ Cultural and Linguistic Competence Guidelines for Residential

Programs▫ Handbook and Appendices for Hiring and Supporting Peer Youth

Advocates▫ Numerous documents translated into Spanish (e.g., SAT; Family

and Youth Tip Sheets)▫ Engage Us: A Guide Written by Families for Residential Providers▫ Promoting Youth Engagement in Residential Settings

BBI website: ww.buildingbridges4youth.org

BBI Contact InformationDr. Gary BlauGary.Blau@samhsa.hhs.gov240-276-1921Beth Caldwellbethcaldwell@roadrunner.com413-644-9319

www.buildingbridges4youth.org

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