A Pilot Trial of a Network Intervention for Youth After Incarceration

Study Overview
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Brief Summary
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A vicious cycle exists between adolescent substance use disorders and youth incarceration. Re-wiring adolescent social networks during community reentry after incarceration can potentially break the cycle of adolescent substance use and youth incarceration. Social networks influence adolescent substance use and delinquent behavior, yet little is known about how to intervene on social networks to improve health. Community reentry is a key opportunity to re-set youths' social networks and re-direct high-risk youth toward a healthier, more supportive network that can foster drug abstinence and reduce recidivism. The investigators hypothesize that an adult who has successfully navigated reentry can guide youth to rewire their social network by encouraging pro-social relationships, troubleshooting basic barriers to healthcare and social services, and helping create linkages to substance use and mental health treatment services. The goal of this study is to measure the impact of a pilot intervention to address two key barriers to accessing behavioral health treatment among recently incarcerated youth: poor care coordination and need for more positive support from the social network. The proposed study intervention, the Whole Person Care (WPC) Reentry Program, is based on the successful adult Transitions Clinic model, and is being adapted for delivery to transition age youth (TAY) by community partners in the Los Angeles County justice system. WPC community health workers (coaches) will provide recently released inmates a formerly incarcerated adult role model who provides care coordination and social support to facilitate access to needed health services, and who actively intervenes to guide TAY youth toward pro-social peers and adults. The investigators propose a pilot longitudinal study of WPC, using a community-partnered participatory research approach. The primary outcome will be reductions in adolescent substance use in response to the intervention (Aim 1). Secondary outcomes will test whether the intervention increases receipt of behavioral health services, decreases recidivism and mental health symptoms, and improves school and work engagement (Aim 2). Finally, the investigators will examine social networks as a potential mechanism by measuring whether youth receiving the intervention report healthier social networks (lower proportion of peers engaging in risky behaviors and a higher number of supportive adults) than control youth (Aim 3).

Detailed Description
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A vicious cycle exists between adolescent substance use disorders (SUD) and youth incarceration. Untreated SUD, often comorbid with mental health problems, contribute substantially to youth incarceration. Among 51,000 US youth detained annually, 50-88% have SUD. Incarceration itself can exacerbate existing mental health disorders and contribute to future substance use. Following incarceration, reentry back into the community of peers and adults is a challenging juncture and a high risk period for re-engaging in substance use. Finally, relapse on substance use leads to recidivism. Within 3 years of release, 75% of adolescents are re-arrested, with highest risk among youth with SUD. Re-wiring adolescent social networks during reentry can potentially break the vicious cycle of adolescent substance use and youth incarceration. Social networks powerfully influence adolescent substance use and delinquent behavior, yet little is known about how to intervene on social networks to improve health. In the investigators prior research, the investigators found that incarcerated youth value relationships with supportive adults and peers who can help them succeed in school and stay out of trouble. Most express plans to stay clean from drugs and stay away from peers who encourage substance use and delinquent behaviors. Yet, during reentry, many youth re-engage with their previous network of risky peers. Why? The investigators have found that upon reentry, youth who lack sufficient social supports and positive role models default back to previous risky social networks, reinforcing further substance use and other risky behaviors. Community reentry is a key opportunity to re-set social networks and re-direct high-risk youth toward a healthier network that can foster drug abstinence and reduce recidivism. Having an available and supportive adult role model can be transformative for youth after incarceration. The investigators hypothesize that an adult who has successfully navigated reentry can actively guide youth to re-wire their social network by encouraging pro-social relationships, troubleshooting basic barriers to healthcare and social services, and creating linkages to SUD and mental health services, to disrupt the viscous cycle. This community-partnered study seeks to measure the impact of an innovative pilot intervention, the Whole Person Care (WPC) Reentry Program, a network community health worker (i.e. coach) intervention that addresses two key challenges for recently incarcerated transition age youth (TAY): poor care coordination in the behavioral health cascade and need for more positive support from the social network. Los Angeles (LA) County has the largest adult and juvenile justice systems in the US and has implemented the WPC Reentry Program to enhance linkages to community behavioral health services. WPC is based on the successful Transitions Clinic model, an intervention with demonstrated efficacy in linking recently incarcerated adults to needed healthcare and improving health outcomes. The model has yet to be implemented for reentry TAY, but has the potential to be transformative at the critical developmental stage of adolescence, when peer social networks are highly dynamic and youth behaviors can affect lifelong trajectories. WPC community health workers will receive formalized training modeled after the adult Transitions Clinic approach and will serve as a formerly incarcerated adult role model who provides care coordination and social support to facilitate access to needed behavioral health services. Tailored for reentry youth, WPC will also include a social network component whereby coaches are trained to actively guide youth toward pro-social peers and adults. Dr. Barnert has been working closely with LA County and this study capitalizes on a unique opportunity to rigorously study WPC. The investigators hypothesize that (1) WPC will reduce adolescent SUD and recidivism and (2) WPC will demonstrate positive associations with other key markers of healthy reentry (e.g., improved mental health). The investigators further hypothesize that shifts towards healthier social networks will mediate these relationships, a potential mechanism the investigators will test. The investigators propose a pilot longitudinal study of WPC, using a community-partnered, participatory research approach. Specific aims are to: Measure the impact of the WPC network coach intervention targeting recently incarcerated youth on decreasing rates of 30-day use and risky use of marijuana, alcohol, and other drug use. Test whether the WPC network coach intervention decreases recidivism, increases receipt of behavioral health services, improves mental health, and enhances school and work engagement. Examine whether recently incarcerated youth receiving the WPC intervention report healthier social networks (lower proportion of peers engaging in risky behaviors and a higher number of supportive adults) than those not receiving the intervention.

Official Title
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A Pilot Trial of a Network Intervention for Youth After Incarceration

Conditions
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Youth Incarceration, Health Care Utilization

Intervention / Treatment
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* Behavioral: Whole Person Care (WPC) Reentry Program


Participation Criteria
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Eligibility Criteria
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Inclusion criteria for youth exiting the adult justice system: Eligible for WPC reentry intervention (determined by Los Angeles County) or has spent at least 1 night in adult jail Ages 18-24 Fluent in English or Spanish Exclusion criteria for youth exiting the adult justice system: Severe cognitive delay Unable to complete surveys in English or Spanish

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 24 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Whole Person Care (WPC) Reentry Program<br>In partnership with LA County Health Agency, Dr. Barnert is adapting the successful Transitions Clinic model developed for reentry adults, to assist recently incarcerated transition age youth link to needed health services and reduce substance use disorder relapse and recidivism. This adaption is informed by Dr. Barnert's prior research on the needs of incarcerated adolescents. The intervention, called the Whole Person Care (WPC) Reentry Program will consist of community health workers (i.e. network coaches) who are formerly incarcerated and formally trained in care coordination and social network coaching, who interact with justice-involved transition age youth pre- and post-release to increase youths' engagement in community SUD and mental health services. Participants in this branch will include youth exiting the adult justice system (ages 18-24). | Behavioral: Whole Person Care (WPC) Reentry Program<br>* Social network intervention to provide care coordination and social support during youth reentry.<br>|
| No Intervention: Control<br>Participants in the control arm will receive usual care reentry healthcare planning post-release, including correctional health provider and court-referred SUD and mental health treatment recommendations, medication prescriptions, written instructions for reinstating Medicaid, and written health discharge summaries. Participants in this branch will include youth exiting the adult justice system (ages 18-24) and youth exiting the juvenile justice system (ages 16-18). | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Frequency of past-month (30-day) marijuana use | Self-reported frequency of past-month (30-day) marijuana use | 3 months post-release | 
| Frequency of past-month (30-day) alcohol use | Self-reported frequency of past-month (30-day) alcohol use | 3 months post-release | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Frequency of past-month (30-day) marijuana use | Self-reported frequency of past-month (30-day) marijuana use | 9 months post release | 
| Frequency of past-month (30-day) alcohol use | Self-reported frequency of past-month (30-day) alcohol use | 9 months post release | 
| Recidivism | Re-arrest (self-report and administrative/probation data) | 3 months post-release | 
| Recidivism | Re-arrest (self-report and administrative/probation data) | 9 months post release | 
| Receipt of behavioral health services | Combined total number of visits to substance use treatment services and mental health services. Combined number of visits will be self-reported and verified by administrative/probation data. | 3 months post-release | 
| Receipt of behavioral health services | Combined total number of visits to substance use treatment services and mental health services. Combined number of visits will be self-reported and verified by administrative/probation data. | 9 months post-release | 
| Mental health | Self reported mental health disorders | 3 months post release | 
| Mental health | Self reported mental health disorders (will be verified by administrative/probation data) | 9 months post release | 
| Substance use disorders | Self reported substance use disorders (will be verified by administrative/probation data) | 3 months post release | 
| Substance use disorders | Self reported substance use disorders (will be verified by administrative/probation data) | 9 months post release | 
| Medications | Self reported medications (will be verified by administrative/probation data) | 3 months post release | 
| Medications | Self reported medications (will be verified by administrative/probation data) | 9 months post release | 
| Delinquency | Number of arrests (will be verified by administrative/probation data) | 3 months post release | 
| Delinquency | Number of arrests (will be verified by administrative/probation data) | 9 months post release | 
| Attitudes towards WPC Reentry intervention (WPC Reentry Participant Response Tool) | Liked intervention; recommend to a friend. Assessed via WPC Reentry Participant Response Tool. Includes 3 items, assessed via 7-point Likert scale. | 3 months post release | 
| Attitudes towards WPC Reentry intervention (WPC Reentry Participant Response Tool) | Liked intervention; recommend to a friend. Assessed via WPC Reentry Participant Response Tool. Includes 3 items, assessed via 7-point Likert scale. | 9 months post release | 
| Psychiatric hospitalizations | Self-reported and health records data | 3 months post release | 
| Psychiatric hospitalizations | Self-reported and health records data | 9 months post release |