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2003 Model Practice Application (Public)

Application Name: 2003 Model Practice Application (Public) : Pima County Health Department : Breaking the Cycle
Applicant Name: Ms. Sherry Daniels, MS, MPH, RN
Practice Title
Breaking the Cycle
Submitting LHD/Agency/Organization
Pima County Health Department


The purpose of the Breaking the Cycle program is to reduce young children’s exposure to violence and to ultimately decrease the number of juvenile delinquents through prevention, early detection and intervention services. Breaking the Cycle (BTC) is a collaboration between:
  • Local law enforcement that refers families of domestic violence to Victim Witness.

  • Victim Witness of Pima County Attorney’s Office who does crisis intervention with these families, focusing on children.

  • Public Health Nursing of Pima County Health Department who provides long term home visitation with these families for support and case management.

  • Second Step of Child & Family Resources which provides a violence prevention curriculum to nine childcare centers in the targeted area.

  • Other collaborators are: Pima Prevention Partnership (PPP) for project management and evaluation, Juvenile Services Coordinating Council (JSCC) as an oversight committee, and Pima County Health Department (PCHD) for financial grant management.

Responsiveness and Innovation
BTC was developed in response to increasing violence among children and adolescents in Pima County. As the result of a community needs assessment, the recommendation was made to address the delinquency following risk factors: trauma experienced by children exposed to family violence, early initiation of aggressive behavior, and family conflict. The focus on prevention rather than intervention makes BTC unique, since many programs dealing with juvenile delinquency focus on the child after delinquent behavior has occurred. BTC is innovative in that it focuses on children ages 0-6 years.

JSCC decided to focus on those children who witnessed family violence in their homes. Police statistics revealed a high rate of domestic violence calls in the Tucson area, many to families with young children. Before the program began, there was a lack of collaboration among agencies dealing with these families. Victim Witness (VW) was not routinely called out to these homes. However, when they were, they focused on the adult victim, not the child(ren). Public Health Nurses (PHN) rarely received referrals from VW. The PHNs often were not aware that DV was an issue for the family, since they did not routinely screen for DV in the course of their visits. Child & Family Resources was familiar with the Second Step Violence Prevention Curriculum, but did not have the means to implement it in area child care centers and had only superficial collaboration with PHNs.

Through BTC, a system of collaboration has been developed between the Tucson Police Department, Pima County Sheriff's Department, Pima County Attorney's Victim Witness Program, Public Health Nursing, Child & Family Resources and Pima Prevention Partnership. When law enforcement is called out to a domestic violence scene where young children are present, a call is made to VW. When VW arrives, they provide crisis intervention to the child and adult victims.

Agency Community Roles
The Pima County Health Department (PCHD) was the lead agency for the initial grant funding and continues to serve as the fiscal agent for the program. PCHD staff provided a leadership role in the initial development, implementation and evaluation of the program. The PCHD PHNs continue to play a vital role in the program by providing home visitation and case management. PCHD staff participates in monthly project partners meeting and provide valuable input into the program.

Other community agencies involved in the development and implementation include Tucson Police Department, Pima County Sheriff's, Pima County Attorney Office Victim Witness, Child & Family Resources, Pima County Health Department Administration, and Pima Prevention Partnership. In addition, through membership in the JSCC, local judicial officials and politicians, business leaders, school administrators and others receive regular updates on the program and provide input as needed. Eight local childcare centers are also involved via implementation of the Second Step program in their centers.

To foster collaboration, program members are engaged in cross training so that all staff members understand the other agencies' roles. This included Public Health Nursing staff going on "ride alongs" with law enforcement officers, attending Second Step staff training and parent nights at the child care centers, and giving presentations on public health nursing at Victim Witness volunteer trainings. Staff from Victim Witness, Pima Prevention Partnership and Second Step went out on home visits with PHNs to further their understanding of what PHNs do on home visits. Monthly partner meetings where staff has the opportunity to discuss program problems/issues with each other maintains the collaborative effort and allows for input into the program.

Costs and Expenditures
Initial three-year funding for the program was secured from Title V Juvenile Justice and Delinquency Prevention through the Arizona Governor's Division for Children. First-year funding was for $193,128. Year two funding was decreased to $144,820 and year three funding is $130,753. This funding source ended on 9/30/03. Supplemental funding has been obtained from the Arizona Attorney General's office, local donations and another year of funding from the Arizona Governor's Office on Children and Families has been obtained.

Program costs include salary and benefits for staff: PHN (initially full-time, now .5 FTE), a violence prevention specialist (1.0 FTE), Victim Witness Advocates (2.0 FTE) and a .25 FTE program evaluator. Other costs include purchase of Second Step curriculum and materials for each childcare center, parent incentives, and stipends to child care centers so staff may attend training, mileage reimbursement, educational literature/videos, bus passes for clients, printing/copying costs, office supplies, training supplies, minivan and software.

In-kind donations were required from each participant and included: office space/utilities, fiscal oversight, PHN coordinator time, PHN time (other than PHN paid for by grant), van insurance and maintenance, and mileage reimbursement.

Program participants are actively working to institutionalize this program within their agencies. Child & Family Resources has integrated the Second Step Curriculum into another program they administer and is working to obtain alternate funding for the violence prevention specialist. Victim Witness is also seeking alternate funding for their coordinator positions so that the vital link with law enforcement is not lost and referrals to PHN will continue. PCHD is providing funding for .5 FTE of the PHN assigned to the program. PHN plans to continue to provide the same level of service to families experiencing domestic violence and has integrated the program throughout the section.

Outcome Process Evaluation
Whether the interventions implemented have an effect on juvenile delinquency will not be known for many years. JSCC is working on developing a system to track children involved in the project to determine if they have any incidents of delinquency. The impact on systems is evidenced by the true collaborative nature of the project. Relationships have been forged between agencies that had not previously worked together. Law enforcement is now aware of the need to involve Victim Witness. Nurses now have a protocol to follow when working with families who have experienced DV and are planning to develop a screening tool for use with all families receiving PHN home visitation. Many PHNs involved with BTC have a greater awareness of DV issues and have changed the way they practice. Clients reported having a positive interaction with law enforcement and VW. Feedback from clients on the effectiveness of PHN visits reveals that clients felt the nurses were caring, able to help them see their own ability to problem solve, children felt safer, family violence incidents decreased, parents were aware of the affects of DV on their children and improved in their ability to parent their children. As of 4/30/03, VW has provided services to 605 families and 942 children within those families. The majority of the families are Hispanic and many are monolingual Spanish speakers. VW provides services to any child under 18 in the home, but 71% of children receiving crisis intervention were in the 0-6 years of age. Data is currently being compiled on the results of the needs assessment and progress questionnaires PHNs give to families. Also being evaluated is the number of referrals to community agencies are made, which agencies families are referred to and the outcome of the referrals.

Lessons Learned
There have been many lessons learned in the process of developing, implementing and evaluating this program. One challenge was the nursing staff’s need to learn law enforcement language and VW’s need to comprehend the referral information. Staff turnover has presented a challenge. It was often difficult to keep the momentum going while new staff learned the program and job responsibilities. Monthly partner meetings and meetings between individual workers to orient new staff to other programs helped reduce the impact. Childcare worker turnover has been significant, requiring repeated trainings of childcare staff on the Second Step curriculum. Two childcare centers were dropped due to lack of commitment, but those spaces were filled by other interested centers. The grant originally proposed that the childcare centers would provide public health nursing with direct referrals of children demonstrating problem behavior; however, there were confidentiality issues that prevented childcare staff from forwarding these children’s names. PHNs decided to serve these families instead by explaining nursing services at the “Parents’ Night” classes. The nurse also staffed several “Ask-A-Nurse” sessions at the centers. PHNs experienced difficulty with some families accepting home visitation. PHNs found that having incentives increased the chance that the family would allow them to visit. Finding funds for these items has been a challenge. Another significant challenge was addressing the issue of staff safety. Some nurses were hesitant to make home visits after reading referrals describing weapons, intimidation, and violence. A protocol was written specifying safety procedures. Finally, law enforcement needs to be frequently encouraged to make the calls to VW. This challenge was addressed by the VW advocates attending change-of-shift briefings, recognizing those officers that did make the call to VW, informing those officers of the referral outcome and providing officers with client feedback.

Key Elements Replication
To be able to replicate this program, the law enforcement community must recognize that they can have a role in preventing juvenile delinquency. The availability of a Victim Witness program or other victim advocacy group is essential, since it is this program that provides the initial crisis interventions for children exposed to DV and their families. In Pima County, Victim Witness has access to services these families may otherwise find difficult to access, such as Victim Compensation Funds. Public Health Nurses or other community nurses that provide home visiting and case management are needed to provide the long-term follow up for families. PHNs are ideal to provide this service since they usually are very familiar with the community, available resources and are able to see how DV effects the population as a whole. Child Care centers that are committed to reducing the aggressive behaviors of children in their care and are willing to work to address this issue are important for the implementation of the Second Steps component. At least one VW advocate should be available to coordinate this program and provide leadership in contacting law enforcement. A minimum of a .5 FTE PHN should be dedicated to the program. More may be needed, dependent on the community size. Currently all 28 PHNs employed by Pima County follow BTC clients. One violence prevention specialist is needed to implement the Second Step curriculum in participating child care centers. BTC took approximately four months from when funding was received to when the first referrals were made to VW and PHN. The four months was needed for cross-training, developing brochures, referral forms and procedures and developing evaluation tools. It took at least another 8 months for most of the “glitches” to be worked out the system. Purchased resources would include the Second Step curriculum and materials, DV related educational materials and videos for staff and clients, client incentives and funds to reimburse childcare centers for staff time and/or substitute teachers while staff are at Second Step training.