Transcript Integrated Dual Diagnosis Services - Illinois Co

Integrated Dual Diagnosis Services:
Implementation
and Program Maintenance
Randi Tolliver, PhD, CADC
Illinois Co-Occurring
Center for Excellence
www.illinoiscoce.org
SAMHSA Definition
“Co-occurring disorders may include any
combination of two or more substance
abuse disorders and mental disorders
identified in the Diagnostic and Statistical
Manual of Mental Disorders-IV (DSM-IV).
There are no specific combinations
of….disorders that are defined uniquely as
co-occurring disorders.”
In “A Report to Congress on the Prevention and Treatment of
Co-Occurring Substance Abuse Disorders and Mental Disorders”
Integrated Dual Diagnosis Services
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Improve quality of life

Promote hopeful interactions

Utilize biopsychosocial treatments
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Promote consumer and family
involvement in service delivery

Promote and increase stable housing
Integrated Dual Diagnosis Services

Promote a recovery concept
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Utilize Recovery Management and/or
Recovery Support Specialists
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Increase continuity of care

Promote employment as an expectation

Increase independent living
Integrated Dual Diagnosis Services
 Co-morbidity
is an expectation, not an
exception.
 There
is no one type of dual diagnosis
program or intervention.
 Motivational
 Substance
enhancement strategies
abuse and mental health
counseling services
Integrated Dual Diagnosis Services
 Multidisciplinary
 Access
teams
to comprehensive services
 Participation
in self-help groups
 Pharmacological
 Interventions
well-being
treatments
to promote health and
Evidence-Based Practice
Two Directions in EBP
 Evidence-Based
•
EB Guidelines, EB Practices, Empiricallysupported (validated) Treatments
 Evidence-Based
•
Interventions:
Process for decision-making:
EB Process, EB Individual Practice
Evidence-Based Guidelines (EBG)
• Different methods for designing guidelines:
global subjective judgment or consensusbased, outcomes based, preference based,
expert opinion, evidence based
• Importance of explicit, evidence-based
process in developing guidelines
Evidence-Based Process (EBP)
• EB Process is a way of doing practice
which involves an individualizing process
whereby evidence is used to make
collaborative decisions with clients and
caregivers. (Mullen, 2004)
• EB Process is the integration of best
research evidence with clinical expertise
and patient values (Sackett et al., 2000).
Systems of Care
 Recovery
Oriented Systems of Care
 Comprehensive,
Continuous, Integrated
Systems of Care Model
• Focused on recovery
• Comprehensive
• Be viewed as seamless by the consumer
• Involve multiple systems
Adapted from SAMHSA Report To Congress 2002
Integrated Services
& Integrated Systems
• Integrated Services
– Designed to improve access and use of all
needed services and resources
• Integrated Systems
– Designed to change service delivery for a
specific population
SAMHSA Report To Congress 2002
Systems Integration
•Success occurs when a comparable
emphasis is placed on integrated services
•Systems integration does not necessarily
require the creation of new services or
agencies
•Should be measured by system-level and
consumer level outcomes
SAMHSA Report To Congress 2002
Recovery-Oriented
Systems of Care
• Support person-centered and self-directed
approaches to care that build on the
strengths and resilience of individuals,
families, and communities to take
responsibility for their sustained health,
wellness and recovery from alcohol and
drug problems.
National Summit on Recovery Conference report, 2005.
ROSC System of Care Elements
• Person-centered
• Family and other ally involvement
• Individualized and comprehensive
services across the lifespan
• Systems anchored in the community
• Continuity of care
National Summit on Recovery Conference report, 2005.
ROSC System of Care Elements
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•
•
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Partnership-consultant relationships
Strength-based
Culturally responsive
Responsiveness to personal belief
systems
• Commitment to peer recovery support
services
• Inclusion of the voices and experiences of
recovering individuals and their families
National Summit on Recovery Conference report, 2005.
ROSC System of Care Elements
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•
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Integrated services
System-wide education and training
Ongoing monitoring and outreach
Outcomes-driven
Research-based
Adequately and flexibility financed
National Summit on Recovery Conference report, 2005.
Comprehensive, Continuous,
Integrated Systems of Care Model
(CCISC)
•4 Basic Characteristics
•8 Principles of Treatment
•12 Steps of Implementation
Kenneth Minkoff, MD
Four Basic Characteristics
of CCISC
1. System Level Change
2. Efficient Use of Existing Resources
3. Incorporation of Best Practices
4. Integrated Treatment Philosophy
Kenneth Minkoff, MD
Eight Principles of Treatment
of CCISC
1. Dual diagnosis is an expectation, not an
exception.
2. All people diagnosed with a COD are not the
same.
3. Empathic, hopeful, integrated treatment
relationships
4. Case management must be balanced with
empathic detachment, expectation, contracting,
consequences, and contingent learning.
Kenneth Minkoff, MD
Eight Principles of Treatment
of CCISC
5. Both disorders should be considered primary.
6. Both mental illness and addiction can be served
within a similar philosophical framework with
parallel phases of recovery.
7. There is no single correct intervention for
COD.
8. Clinical outcomes for COD must also be
individualized.
Kenneth Minkoff, MD
Twelve Steps of Implementation
of CCISC
1.
2.
3.
4.
Integrated system planning process
Formal consensus on CCISC model
Formal consensus on funding the CCISC model
Identification of priority populations, and locus of
responsibility for each
5. Development and implementation of program
standards
6. Structures for intersystem and interprogram care
Kenneth Minkoff, MD
coordination
Twelve Steps of Implementation
of CCISC
7. Development and implementation of practice
guidelines
8. Facilitation of identification, welcoming, and
accessibility
9. Implementation of continuous integrated
treatment
10. Development of basic dual diagnosis capable
competencies for all clinicians
11. Implementation of a system wide training plan
12. Development of a plan for a comprehensive
program array
Kenneth Minkoff, MD
Organizational Environment
Differences:
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Treatment
philosophy
Treatment
practice
Relationships
Common ground:

Values and
principles

Guidelines

Outcome measures

Vocabulary

Basic competencies
Organizational Change


Understanding the organization’s
model
Multi-level organizations
•
•
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Mutual and conflicting needs
Traditional versus innovative ways of
communicating
Systems tend to resist substantial
change
Adapted from Hendrickson, E. L (2006)
Adopting Evidence Based Practices
in an Organization
• Address organizational and clinical elements in
development and implementation.
• Engage and prepare the organization, programs,
and staff for changes.
• Develop a working partnership with the treatment
team.
• Promote staff ownership for the practices.
Program Development

Utilize evidence-based or best practices
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Utilize a competency-based perspective
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Employ recovery support specialists
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Develop a plan to address housing needs

Employ employment specialists
Program Development

Develop policy & procedures for program
operations
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Develop a clear understanding of target
population and program goals

Develop a marketing strategy that will
ensure adequate numbers of consumers
are engaged
Program Development

Develop a realistic time frame for hiring
and training staff
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Establish a functional and clear admission
and referral process
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Allow easy accessibility to program
services across the continuum of care
Questions to Consider
for Development and Implementation

Currently, which co-occurring treatment
services are being offered to which consumers?
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Where in the continuum of care are the
services being offered?
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Do current services demonstrate the qualities of
“effective” services?

Do the services meet the needs of the
community?
SAMHSA Tip 42
Questions to Consider

What resources are available?
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What are the barriers to implementing the EBP?
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What are the priorities?
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What is the capacity of the agency to implement
comprehensive, integrated services?
Questions to Consider
 What
are the core competencies needed
for staff to provide effective services?
 What
 What
services are currently offered?
modifications will need to be made in
the evidence based practice?
Implementation Challenges

Physician or psychiatrist staffing
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Physical resources

Billing and reimbursement issues
McGovern, Xie, et. al. (2006).
Implementation Challenges

Identifying and responding to gaps in
workforce competencies, certifications,
and licensure
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Addressing increases in staff concern
related to changes in roles and
responsibilities
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Addressing discrepancies in record
keeping
Implementation Challenges

Addressing organizational structure and
policies
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Resolving differences in treatment
philosophies
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Establishing a cohesive multidisciplinary
team
Implementation Challenges
• Developing treatment manuals, tool kits,
online support.
• Addressing the organizational components:
Do we modify the intervention or modify
environment?
• Assessing fidelity to EBP model through
use of fidelity measures.
Fidelity and Indexes

General Organization Index (GOI)

Integrated Dual Diagnosis Treatment (IDDT)
Fidelity Scale

Dual Diagnosis Capability in Addiction Treatment
(DDCAT) Index
& Dual Diagnosis Capability in Mental Health
Treatment (DDCMHT) Index

Motivational Interviewing Treatment Integrity
(MITI)
General Organizational Index
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Program Philosophy
Eligibility/ Consumer Information
Penetration
Assessment
Individualized Treatment Plan
Individualized Treatment
Training
Supervision
Process Monitoring
Outcome Monitoring
Quality Assurance
Consumer Choice Regarding Service Provision
IDDT Fidelity Scale
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Multidisciplinary Team
Stage-Wise Interventions
Access to Comprehensive DD Services
Time-Unlimited Services
Outreach
Motivational
Substance Abuse Counseling
Group DD Treatment
Family Psychoeducation on DD
Participation in Alcohol & Drug Self-Help Groups
Pharmacological Treatment
Interventions to Promote Health
Secondary Interventions to Substance Abuse
Treatment Non-Responders
Dual Diagnosis Capability
in Addiction Treatment
(DDCAT) Index
1.
2.
3.
4.
5.
6.
7.
Program Structure
Program Milieu
Clinical Process: Assessment
Clinical Process: Treatment
Continuity of Care
Staffing
Training
McGovern et al. (2006).
Assessing
Motivational Interviewing
• A behavioral coding system
• Provides an answer to the question: How
well or poorly is an individual using
Motivational Interviewing strategies?
• Provides data that can be used to increase
Motivational Interviewing skills.
Motivational Interviewing Fidelity
• Training Protocol
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Awareness building
Knowledge-focused training
Skills-based training
Abilities training
• Clear and focused supervision
• Taped Motivational Interviewing Assessment
sessions
• Coding protocol
• Feedback and instruction for improving skills
National Institute on Drug Abuse, (2001).
Program Commitment Plan

Specific statements of services to be
implemented

Identification of individual(s) to monitor
implementation

Identification of ways to measure
effectiveness of services

Method for implementing services
Adapted from Hendrickson, E. L (2006)
Program Commitment Plan

Development of timeline for
implementation

Process to determine effectiveness of plan
implementation

Method for ongoing review and
modification of the plan
Adapted from Hendrickson, E. L (2006)
Implementation Index
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•
•
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Organizational and Contextual Factors
Implementation Strategies
Program Culture
Staffing & Training
Evaluation
Other Implementation Activities
McGovern et al. (2006).
Paradigm Shifts
Interactive Staff Training
•Focus is on the team rather than the
individual
•Goal is the development of a user-friendly
program
Interactive Staff Training
• Work with team members from several
teams.
• Meet with team on site.
• Meet monthly for one hour.
• 1 year commitment.
September is National Alcohol
and Drug Addiction
Recovery Month
Real People, Real Recovery
Celebrate with us in September 2008.
• www.recoverymonth.gov
• www.illinoiscoce.org
References
• Corrigan, P.W. & McCracken, S.G. (1997). Interactive
staff training: Rehabilitation teams that work. New
York: Plenum.
• Evans, K. & Sullivan, J. M. (2001). Dual Diagnosis:
Counseling the Mentally Ill Substance Abuser (2nd Ed.).
New York: Guilford.
• Gibbs, L.E. (2003). Evidence-based practice for the
helping professions: A practical guide with integrated
multimedia. Pacific Grove, CA: Brooks/Cole-Thompson
Learning.
• Hendrickson, E. L (2006). Designing, Implementing,
and Managing Treatment Services for Individuals with
Co-Occurring Mental Health and Substance Use
Disorders: Blueprints for Action. Binghampton, NY:
Haworth Press.
References
• Hendrickson, E. L. & Schmal, M. (1993). Dual Disorders
Page, TIE Lines, 10 (3), 11.
• McGovern, M. P., Giard, J., Brown, J., Comaty, J., &
Riise, K. (2006). The Dual Diagnosis Capability in
Addiction Treatment (DDCAT): A Toolkit for Enhancing
Addiction Only Service (AOS) Programs and Dual
Diagnosis Capable (DDC) Programs. Unpublished
manuscript, Dartmouth Medical School.
• McGovern, M.P., Xie, H., Segal, S. R., Siembab, L., &
Drake, R. E. (2006). Addiction treatment services and cooccurring disorders: Prevalence estimates, treatment
practices, and barriers. Journal of Substance Abuse
Treatment (31), 276-275.
References
•
Minkoff, K., & Cline, C. A. (2004). Changing the
World: The Design and Implementation of
Comprehensive Continuous Integrated Systems of
Care for Individuals with Co-Occurring Disorders.
Psychiatric Clinics of North America, 27, 727-743.
•
Mueser, K.T., Noordsy, D.L., Drake, R.E., & Fox, L.
(2003). Integrated treatment for dual disorders: A
guide to effective practice. New York: Guilford.
•
Regier, D. A., Farmer, M. E., Rae, D. S., et al.
(1990). Comorbidity of mental disorders with
alcohol and other drug abuse: Results from the
Epidemiologic Catchment Area (ECA) Study.
Journal of American Medical Association, 264,
2511-2518.
References
• Sackett, D.L., Richardson, W.S., Rosenberg, W. M. C.,
& Haynes, R. B. (2000). Evidence-Based Medicine:
How to Practice and Teach Evidence Based Medicine
(2nd ed.). London: Churchill-Livingstone.
• http://www.samhsa.gov/reports/ co_occur_home.htm
– SAMHSA Report to Congress on The Prevention and
Treatment of Co-Occurring Substance Abuse Disorders and
Mental Disorders