Transcript dual diagnosis capability in addiction treatment

INTRODUCTORY TRAINING FOR USE
OF THE DDCAT & DDCMHT INDEXES
WHY FOCUS ON
CO-OCCURRING DISORDERS?
1. Substance use disorders are common in people with
mental health disorders
2. Mental health disorders are common in people with
substance use disorders
3. Co-occurring disorders lead to worse outcomes and
higher costs than single disorders
4. Evidence-based models exist and can be implemented
5. Providers and consumers want a better system and
services
6. Few (<10%) people get the treatments they need.
Courtesy of Mark McGovern, Ph.D.
COMORBIDITY OF SUBSTANCE USE AND
SPECIFIC AXIS I PSYCHIATRIC DISORDERS
Any
Substance
Alcohol
Diagnosis
Other Drug
Diagnosis
Schizophrenia
47%
4.6
33.7%
3.3
27.5%
6.2
ASPD
83.6% 29.6
73.6%
21.0
42%
13.4
Anxiety disorders 23.7%
1.7
17.9%
1.5
11.9%
2.5
Phobia
22.9%
1.6
17.3%
1.4
11.2%
2.2
Panic disorder
35.8%
2.9
28.7%
2.6
16.7%
3.2
OCD
32.8%
2.5
24%
2.1
18.4%
3.7
Bipolar Disorder
60.7%
7.9
46.2%
5.6
40.7%
11.1
Major depression
27.2%
1.9
16.5%* 1.3
18%
3.8
Regier DA et al. JAMA. 1990(Nov 21);264(19):2511-2518
LIFETIME RISK OF ANY MENTAL HEALTH
DISORDER BY SUBSTANCE USE DISORDER
 Cocaine
76.1% (11.3)
 Barbiturates
74.7% (10.8)
 Hallucinogens
69.2% (8.0)
 Opiates
65.2% (6.7)
 Alcohol
36.6% (2.3)
Regier DA et al. JAMA. 1990(Nov 21);264(19):2511-2518
Past Year Treatment of Adults with Both
Serious Psychological Distress (SPD)
and SUD (2006)
39.60
Tx for MH Problems
Tx for SUD Only
Tx for SPD and SUD
No Tx
2.8
49.2
8.4
5.6 Million adults with co-occurring SPD
and substance use disorder.
SOURCE: 2007 National Survey on
Drug Use and Health, SAMHSA.
Past Year Treatment of Adults with
Both MDE and AUD
48.6
Tx for MDE only
Tx for Alcohol Only
Tx for MDE and Alcohol
No Tx
40.7
1.9
8.8
SOURCE: 2007 National Survey on Drug Use and Health, SAMHSA.
So, How Do We Treat COD?
TIP 42
Guiding Principles
and Recommendations
Six Guiding Principles
(SAMHSA, TIP 42)
•
•
•
•
•
•
Employ a recovery perspective
Develop a phased approach to treatment
Plan for cognitive and functional impairments
Provide access
Complete a full assessment
Achieve integrated treatment
- Treatment Planning and Review
- Psychopharmacology
• Ensure continuity of care
Vision of Fully
Integrated Treatment
• One program that provides treatment
for both disorders
• Mental and substance use disorders are
treated by the same clinicians
• The clinicians are trained in
psychopathology, assessment, and treatment
strategies for both disorders
Vision of Fully
Integrated Treatment (continued)
• Treatment is characterized by a slow pace
and a long-term perspective
• Providers offer motivational counseling
• 12-Step groups are available to those who
choose to participate
• Pharmacotherapies are utilized according
to consumers’ psychiatric and other medical
needs
• Sensitivity to issues of trauma
Quick Exercise—
Levels of Program Capacity
Beginning
Addiction
Only
Treatment
Intermediate Advanced
Addiction
Addiction
COD
COD
Capable
Enhanced
Fully
Advanced Intermediate Beginning
Integrated Mental Health Mental Health Mental Health
COD
COD
Only
COD
Integrated
Capable
Treatment
Enhanced
What challenges have you encountered in
moving toward the center?
What have you done to
overcome these challenges?
WHY DO WE NEED TO MEASURE
CO-OCCURRING CAPABILITY?
1.
2.
3.
4.
Generic terms “integrated” or “enhanced”
are “feel good” rhetoric but lack specificity.
Systems and providers seek guidance,
objective criteria and benchmarks for providing
the best possible services.
Patients and families should be informed about
the range of services, to express preferences and
make educated treatment decisions.
Change efforts can be focused and outcomes of
these initiatives assessed.
Courtesy of Mark McGovern, Ph.D.
SPECIFIC AIMS
1. To develop an index that can objectively determine the
dual diagnosis capability of addiction treatment
services.
2. To develop practical operational benchmarks on key
dimensions, and to determine if changes can be made
& measured.
3. To identify change strategies that are particularly
effective for enhancing the dual diagnosis capability of
addiction treatment services
DDCAT INDEX: DEVELOPMENT
• Practical program level policy, practice and
workforce benchmarks: Based on scientific
literature and expert consensus
• Observational methodology: Interviews;
Document review; Social, environmental &
cultural ethnography (vs. self-report)
• Iterative process of measure refinement: Field
testing and psychometric analyses
• Materials: Index, manual, toolkit & Excel
workbook for scoring and graphic profiles
Courtesy of Mark McGovern, Ph.D.
IS THERE A CONCEPTUAL MODEL THAT
COULD GUIDE RESEARCH AND PRACTICE
FOR ADDICTION TREATMENT?
• The American Society of Addiction Medicine (ASAM)
Patient Placement Criteria Second Edition Revised
(PPC-2R) outlined the framework for a model
• The ASAM-PPC-2R is designed for addiction
treatment services
• The ASAM-PPC-2R patient placement criteria have
been widely adopted in public and private community
addiction treatment
ASAM TAXONOMY
OF DUAL DIAGNOSIS SERVICES
(ASAM, 2001)
• ADDICTION ONLY SERVICES (AOS);
MENTAL HEALTH ONLY (MHOS)
• DUAL DIAGNOSIS CAPABLE (DDC)
• DUAL DIAGNOSIS ENHANCED (DDE)
ADDICTION ONLY SERVICES (AOS);
MENTAL HEALTH ONLY (MHOS)
Programs that either by choice or for lack of
resources, cannot accommodate patients
who have psychiatric illnesses that require
ongoing treatment, however stable the
illness and however well-functioning the
patient.
Courtesy of Mark McGovern, Ph.D.
DUAL DIAGNOSIS CAPABLE (DDC)
Programs that have a primary focus on the
treatment of substance-related disorders OR
mental health disorders, but are also capable of
treating patients who have relatively stable
diagnostic or sub-diagnostic co-occurring
mental health problems.
Courtesy of Mark McGovern, Ph.D.
DUAL DIAGNOSIS ENHANCED (DDE)
Programs that are designed to treat patients
who have more unstable or disabling cooccurring mental disorders in addition to their
substance-related disorders.
Courtesy of Mark McGovern, Ph.D.
DETERMINING DUAL DIAGNOSIS
CAPABILITY BY ADDICTION TREATMENT
PROVIDER SURVEY
Addiction Only Services (AOS)
97 (23.0%)
Dual Diagnosis Capable (DDC)
275 (65.3%)
Dual Diagnosis Enhanced (DDE)
(n=453)(McGovern et al, 2006b)
49 (11.6%)
THE NEED FOR A
MORE OBJECTIVE ASSESSMENT OF
ADDICTION TREATMENT SERVICES’
DUAL DIAGNOSIS CAPABILITY
• ASAM offers the road map, but no operational
definitions for categories or services
• Fidelity: Adherence to an evidence-based
practice or model
• Fidelity scales: Objective ratings of adherence
in mental health services research
• Can we apply fidelity scale methods to
estimate dual diagnosis capability?
APPLYING THE FIDELITY SCALE
METHODOLOGY FOR A
MORE OBJECTIVE ASSESSMENT OF
DUAL DIAGNOSIS CAPABILITY
•
•
•
•
•
Site visit (yields data beyond self-report)
Multiple sources:
1) Documents and materials
2) Ethnographic observation
3) Interviews with staff and patients
Unit of analysis: Program
•
“Triangulation” of data
Courtesy of Mark McGovern, Ph.D.
DUAL DIAGNOSIS CAPABILITY IN
ADDICTION TREATMENT (DDCAT) INDEX:
DEVELOPMENT & FEASIBILITY
• Index (instrument) construction
• Feedback from experts in dual-diagnosis
treatment and research, state agency
administrators, addiction treatment providers,
and fidelity measure experts
• Field testing the DDCAT index 1.0 (2003)
• Site visits in programs
• Found to be doable, useful information for
providers and psychometrically sound
DDCAT PSYCHOMETIC PROPERTIES
•
•
•
•
•
•
•
Reliability
Median alpha = .81 (Range .73 to .93)
Inter-rater reliability (MO): .76
Inter-rater reliability (LA): .84
Kappa (MO) = .67 (median)
Sensitivity to change (CT): p < .05 @ 9 months
Validity
Correlation with IDDT Fidelity Scale: Median = .69 (.38 to .82)
Relationship with psychiatric severity levels at admission:
Increasing access for persons with co-occurring disorder
from AOS to DDC to DDE level programs (p<.001)
(Gotham et al, 2004; McGovern et al, 2006, 2007; Brown & Comaty, 2007)
DUAL DIAGNOSIS CAPABILITY IN MENTAL
HEALTH TREATMENT (DDCMHT) INDEX
•
•
•
•
Designed by Drs. Heather Gotham, Jessica Brown &
Joseph Comaty as companion to DDCAT but for use in
mental health programs.
Common metric and method: 35 items, 7 dimensions,
programs categorized as Mental Health Only Services
(MHOS), DDC or DDE
More likely presentation of QIII patients in mental
health system (than addiction treatment system)
Makes comparisons between systems possible
DUAL DIAGNOSIS CAPABILITY IN MENTAL
HEALTH TREATMENT (DDCMHT) INDEX
•
•
•
•
Focus on substance use capable services within a
mental health program
Compares with the Integrated Dual Disorder
Treatment model (IDDT) and fidelity scale (which
focus on specialized team within a program/agency)
Less data are presently available
Being used in statewide change initiatives in
Louisiana, Missouri, New York and Vermont
DDCAT & DDCMHT (3.2): 7 DIMENSIONS
& CONTENT OF 35 ITEMS
Dimension
Content of items
I
Program Structure
Program mission, structure and financing, format for
delivery of mental health or addiction services.
II
Program Milieu
Physical, social and cultural environment for persons
with psychiatric or substance use problems.
III
Clinical Process:
Assessment
Processes for access and entry into services,
screening, assessment & diagnosis.
IV
Clinical Process:
Treatment
Processes for treatment including pharmacological
and psychosocial evidence-based formats.
V
Continuity of Care
Discharge and continuity for both substance use and
psychiatric services, peer recovery supports.
VI
Staffing
Presence, role and integration of staff with mental
health and/or addiction expertise, supervision process
VII
Training
Proportion of staff trained and program’s training
strategy for co-occurring disorder issues.
DDCAT/DDCMHT
INDEX RATINGS
1-
2345-
Addiction Only Services(AOS) or
Mental Health Only Services (MHOS)
Dual Diagnosis Capable (DDC)
Dual Diagnosis Enhanced (DDE)
DDCAT/DDCMHT DATA COLLECTION:
SOURCE, DIMENSION & TIME ALLOCATION
•
•
•
•
•
Meet with agency leadership (I, VI, VII)(30’)
Tour of program (II, III)(30’)
Meet with clinicians and other staff (III-VI)(30’)
Meet with patients (II, V)(30’)
Observe clinical interaction or team meetings when
possible (II-V)(30’)
• Review documents including medical records,
brochures, program schedules, any patient/family
handouts, policy & procedure manual (I-V)(60’)
I.
PROGRAM STRUCTURE
I.A. Primary treatment focus as
stated in mission statement
DDCAT:
Is the stated focus
addiction only, primarily
addiction (with an
acknowledgement of
psychiatric problems) or
dual diagnosis?
DDCMHT:
Is the stated focus
mental health only,
primarily mental health
(with acknowledgement
of substance use
problems) or dual
diagnosis?
I. PROGRAM STRUCTURE
I.B. Organizational certification
and licensure
What does licensure/certification permit?
Are there impediments to providing certain types
of services?
Are these impediments real?
I.
PROGRAM STRUCTURE
I.C. Co-ordination and collaboration
with mental health or addiction services
DDCAT:
How & where are
psychiatric services
provided? Through
relationships or
integrated? Are these
relationships formalized
& documented?
DDCMHT:
How & where are
addiction treatments
provided? Through
relationships or
integrated? Are these
relationships formalized
& documented?
I. PROGRAM STRUCTURE
I.D. Financial incentives.
How do billing structures limit or incentivize
services for persons with addiction and/or
psychiatric disorders?
II. PROGRAM MILIEU
II.A. Routine expectation of and
welcome to treatment for both
disorders.
What patients are expected and welcomed?
How is this reflected in agency documents?
II. PROGRAM MILIEU
II.B. Display and distribution of
literature and patient
educational materials.
What kind of information is posted on walls, on
display in waiting areas, and included in patient
& family handouts and printed materials?
III. CLINICAL PROCESS: ASSESSMENT
III.A. Routine screening methods for
psychiatric or substance use symptoms
DDCAT:
DDCMHT:
Are there routines or systems
to screen for psychiatric
problems? Are screening
instruments used?
Are procedures systematic?
Are there routines or
systems to screen for
substance use problems?
Are screening instruments
used?
Are toxicological data
gathered?
III. CLINICAL PROCESS: ASSESSMENT
III.B. Routine assessment if
screened positive for
psychiatric symptoms
If a patient screens positive, are more detailed
assessments triggered?
Are these assessments formalized & integrated?
III. CLINICAL PROCESS: ASSESSMENT
III.C. Psychiatric and substance
use diagnoses made and
documented
If assessments are conducted, are psychiatric
diagnoses made in addition to
the substance use disorder?
Are substance use disorder diagnoses made in
addition to the psychiatric disorder?
III. CLINICAL PROCESS: ASSESSMENT
III.D. Psychiatric and substance
use history reflected in
medical record.
Are the chronologies and treatment course of
disorders gathered (and recorded)?
III. CLINICAL PROCESS: ASSESSMENT
III.E. Program acceptance based on
symptom acuity: Low, moderate, high
DDCAT:
DDCMHT:
What happens to patients
who call or present for
services with stable
psychiatric symptoms? Or,
unstable ones?
What happens to patients
who call or present for
services with substance use
in remission? Or, active
substance use or
intoxication? of addiction
treatment?
III. CLINICAL PROCESS: ASSESSMENT
III.F. Program acceptance based on
severity and persistence of disability:
Low, moderate, high
DDCAT:
DDCMHT:
What happens to patients
with histories or records of
severe and persistent
psychiatric problems? Severe
mental illness?
What happens to patients
with histories or records of
severe substance
dependence, and repeated
patterns of compulsive use?
III. CLINICAL PROCESS: ASSESSMENT
III.G. Stage-wise assessment
Is stage of motivation assessed and documented?
Is motivation to change and to use treatment
assessed for both substance use and
mental health problems?
IV. CLINICAL PROCESS: TREATMENT
IV.A. Treatment plans
Do treatment plans show an equivalent and
integrated focus on both substance use and
psychiatric disorders, or do they primarily focus
on substance use (DDCAT) or
psychiatric (DDCMHT) issues only?
IV. CLINICAL PROCESS: TREATMENT
IV.B. Assess and monitor interactive
courses of both disorders.
Are changes and/or progress with
status and symptoms of both psychiatric
and substance use disorders followed
(and noted)?
IV. CLINICAL PROCESS: TREATMENT
IV.C. Procedures for psychiatric
or substance use emergencies and
crisis management
Are there definite protocols for
psychiatric or substance use crises
and/or those at high-risk?
IV. CLINICAL PROCESS: TREATMENT
IV.D. Stage-wise treatment
Is stage of motivation assessed on an ongoing basis?
Can treatment be revised based upon changes in
motivation?
Are assessments and treatments focused on differential
stages in patient motivation to change
(and get help with) both mental health and
substance use problems?
IV. CLINICAL PROCESS: TREATMENT
IV.E. Policies and procedures for
medication evaluation,
management, monitoring and
compliance
Are medications acceptable?
Are certain medications unacceptable?
Are medications routine & integrated?
Are psychiatric and/or addiction medications available?
IV. CLINICAL PROCESS: TREATMENT
IV.F. Specialized interventions with
mental health (DDCAT) or addiction
(DDCMHT) content
DDCAT:
DDCMHT:
Are therapies available that
focus on addiction only,
generic psychological
concerns, or focused on
specific psychiatric disorders
(in addition to substance use
treatments)?
Are therapies available that
focus on mental health only,
generic lifestyle or
behavioral concerns or on
specific substance use
disorders?
IV. CLINICAL PROCESS: TREATMENT
IV.G. Education about co-occurring psychiatric
disorder and or substance use and
integrated treatment
Is information available on how substance use
impacts a psychiatric disorder and vice versa? Is
information available about how co-occurring
disorders affect treatment and recovery?
IV. CLINICAL PROCESS: TREATMENT
IV.H. Family education and support
Are family members provided information
on how substance use impacts a
psychiatric disorder and vice versa?
What kind of support is available for
families on these issues?
IV. CLINICAL PROCESS: TREATMENT
IV.I. Specialized interventions to
facilitate use of peer support
groups in planning or during treatment
In facilitating the connection to
peer recovery support groups,
how are psychiatric disorders considered?
How are substance use disorders considered?
Are specialized introductions available?
IV. CLINICAL PROCESS: TREATMENT
IV.J. Availability of peer recovery supports for
patients with CODs
Are peer supports and role models available for
patients with co-occurring substance use and
psychiatric disorders?
If so, are they on or off site, integrated with
programming?
V. CONTINUITY OF CARE
V.A. Co-occurring disorder
addressed in discharge
planning process
Is recovery from both
psychiatric and substance use disorders
considered when developing a discharge plan?
V. CONTINUITY OF CARE
V.B. Capacity to maintain treatment
continuity
How is treatment terminated or continued?
Is this equivalent for both addiction and
psychiatric disorders?
V. CONTINUITY OF CARE
V.C. Focus on ongoing recovery
issues for both disorders
Are the disorders seen as acute or chronic, short-term
or long-term, primary or secondary?
How is recovery envisioned and planned?
V. CONTINUITY OF CARE
V.D. Facilitation of peer support groups for COD is
documented and a focus in discharge planning, and
connections are insured to community peer recovery
support groups.
Is the potential increased peer support group linkage
difficulty for the person with a psychiatric disorder
anticipated and planned for?
How is it dealt with?
V. CONTINUITY OF CARE
V.E. Sufficient supply and
compliance plan for
medications is documented
How is the need for continued prescribing and
medication supply dealt with?
Are both psychiatric and addiction medications
made available?
VI. STAFFING
VI.A. Psychiatrist or other physician or
prescriber of psychotropic (DDCAT) or
addiction (DDCMHT) medications
What is the relationship with a psychiatrist,
physician, or nurse practitioner
(or other licensed prescribers)?
VI. STAFFING
VI.B. On site clinical staff members with
mental health (DDCAT) or
drug and alcohol (DDCMHT) licensure or
competency
Are any staff licensed to provide
mental health services?
Addiction services?
Co-occurring services?
What percentage of all staff ?
VI. STAFFING
VI.C. Access to mental health (DDCAT)
or addiction (DDCMHT)
supervision or consultation
What is the arrangement for mental health or addiction
treatment supervision and/or consultation for
non-licensed staff ?
VI. STAFFING
VI.D. Case review, staffing or utilization review
procedures emphasize and support COD
treatment.
Is there a protocol to review the progress or process of
treatments for psychiatric and substance use disorders?
VI. STAFFING
VI.E. Peer/Alumni supports are
available with co-occurring
disorders
Are role models available for persons with
co-occurring addiction and psychiatric disorders?
VII. TRAINING
VII.A. Direct care staff members have basic
training in prevalence, common signs &
symptoms, screening and assessment for
psychiatric symptoms and disorders
(DDCAT) and substance use symptoms
and disorders (DDCMHT).
Who has basic training in screening & assessment?
Is training documented?
VII. TRAINING
VII.B. Direct care staff are cross-trained in mental
health and substance use disorders,
including pharmacotherapies & have specialized
training in treatment of persons with COD.
Who is trained?
Is staff training guided and monitored?
What percentage of all staff ?
DDCAT/DDCMHT EXCEL WORKBOOK:
SUMS & AVERAGES SCORES,
GRAPHIC PROFILE
• Complete “face” page of Excel workbook
• Transfer scores from rating scale onto Excel
workbook scoring page (no need to calculate
dimension averages)
• Review dimension averages and program
categorization: AOS/MHOS, DDC or DDE
• Review DDCAT/DDCMHT profile line graph
DDCAT/DDCMHT INDEX:
SUMMARY & FEEDBACK
• Parallel process to clinical interaction:
In both respect and tone MI/MET like
• Assessing organizational stage/targets of change
• Affirmation of strengths
• Elicit concerns and/or areas of potential growth
and perceived barriers
• Discuss potential strategies for enhancement
• Format: Verbal and/or written (Integrative summary
letter and graphic profile)
DDCAT/DDCMHT PROFILE:
PRACTICAL GUIDANCE FOR PROVIDERS
5
DDE 4.5
4
3.5
DDC
3
2.5
2
1.5
AOS/
MHOS
1
0.5
0
I. Program
Structure
II. Program
Milieu
III. Clinical
Process:
Assessment
IV. Clinical
Process:
Treatment
V. Continuity
of Care
VI. Staffing
VII. Training
DDCAT/DDCMHT INDEX:
PROVIDER EXPERIENCES
• Very positive
• Appreciate concrete suggestions about potential
enhancement of services
• Requests for specific information: training,
screening measures, evidence-based treatments
• Verification of real financial constraints
• Curiosity about other programs, states
• Interest in measuring change over time
• Value use of graphic DDCAT/DDCMHT profiles
DDCAT/DDCMHT INDEXES:
SELF-ADMINISTERED FORMATS
• Several efforts to utilize DDCAT index as selfadministered measure: Economic, practical,
less intensive resource issue
• Balancing accuracy with practicality
• Projects underway in: MA, NJ, Australia, IN
• Comparison data available only for the
Australian sample, and previous research
in CT
DDCAT: SELF VS. INDEPENDENT
RATINGS (n=14 agencies in Australia)
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
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USING THE DDCAT/DDCMHT
TO GUIDE AND MEASURE CHANGE
• Use of the DDCAT/DDCMHT as assessment
method at baseline and as a measure of change over
time.
• Formal implementation and change plan
development
• Co-Occurring State Incentive Grant (COSIG)
initiatives
• Private non-profit agencies: CQI process
• Use within NIATx change process
DDCAT PROFILE:
An Outpatient Program in Baton Rouge
5
DDE 4.5
4
3.5
DDC
3
2.5
2
1.5
AOS
1
0.5
0
I. Program
Structure
II. Program
Milieu
III. Clinical
Process:
Assessment
IV. Clinical
Process:
Treatment
V. Continuity
of Care
VI. Staffing
VII. Training
DDCAT/DDCMHT PROFILE CASE STUDY:
UNDERACHIEVING PROGRAM
DDE
5.0
4.5
4.0
3.5
DDC
3.0
2.5
2.0
1.5
AOS
1.0
0.5
0.0
Program
Structure
Program
Milieu
Clinical
Process:
Assessment
Clinical Continuity of
Process:
Care
Treatment
Staffing
Training
DDCAT/DDCMHT PROFILE CASE STUDY:
OVERACHIEVING PROGRAM
5.0
DDE
4.5
4.0
3.5
3.0
DDC
2.5
2.0
1.5
1.0
AOS 0.5
0.0
Program
Structure
Program
Milieu
Clinical
Process:
Assessment
Clinical
Process:
Treatment
Continuity of
Care
Staffing
Training
DDCAT PROFILES:
3 programs within a single agency
DDE
5
4.5
4
3.5
DDC
3
2.5
2
1.5
1
0.5
IOP-Adult
IOP-Adolescent
Methadone Maintenance
Training
Staffing
Continuity
of Care
Clinical
Process:
Treatment
Clinical
Process:
Assessment
Program
Milieu
0
Program
Structure
AOS
DEVELOPING A PROGRAM
IMPLEMENTATION OR
CHANGE PLAN USING
DDCAT/DDCMHT DATA
1.
2.
3.
4.
5.
6.
Identify the DDCAT/DDCMHT dimension (Goal)
Identify the DDCAT/DDCMHT item(s) (Objectives)
Identify the “Intervention”
Identify the responsible persons
Identify the Target Date
Identify Measurable Outcomes
DRAFT IMPLEMENTATION PLAN
FOR THE BATON ROUGE PROGRAM
D GOAL
OBJECTIVE
II Program
Milieu
Make milieu more welcoming; Provide
handouts to patients, families; Change some
items on walls.
Develop educational group for patients on
IV Clinical:
common psychiatric disorders, include segment
Treatment in family night.
VII Training
Get all existing staff basic training in COD
issues; Add to new staff in-service orientation.
STATEWIDE DDCAT/DDCMHT CHANGE
Vermont Program Capability
18
17
16
Number of programs
14
12
12
10
Mental
Health/Addiction Only
Services
9
Dual Diagnosis
Capable
8
6
4
4
2
0
2007
2008
RWJ FUNDED
MULTI-STATE LEARNING COLLABORATIVE
• Purpose: To learn from one another’s experience and efforts to
improve services for persons with co-occurring disorders
(policy, practice & workforce); Most have in common the use
of DDCAT/DDCMHT measures
• Data sharing agreement; Combined data set (9 states)
• 13 “official” member states (+ LA County);
10 active (+LA County)
• One face-to-face meeting (2007); Monthly conference calls
since
• Focus varies: Measure specific issues; successful and
unsuccessful projects; sustainability questions
COLLABORATIVE DATABASE:
ADDICTION TREATMENT PROGRAMS (n=170)
Level of Care
N (%)
Outpatient
45 (26%)
Intensive Outpatient
46 (27%)
Residential
70 (41%)
Inpatient
1 (1%)
Methadone Maintenance
8 (5%)
COLLABORATIVE :
MENTAL HEALTH TREATMENT PROGRAMS
(n=58)
Level of Care
Outpatient
N (%)
53 (91%)
Partial Hospitalization
3 (5%)
Inpatient
2 (4%)
DDCAT/DDCMHT BASELINE PROGRAM
CATEGORIES
DDCMHT (n=58)
DDCAT (n=170)
1%
19%
7%
80%
AOS
DDC
DDE
93%
MHOS
DDC
DDE
DDCAT/DDCMHT PROGRAM CATEGORIES:
BASELINE AND 9-12 MONTH FOLLOW-UP
DDCAT Baseline (n=71)
DDCAT Follow-up (n=71)
13%
37%
63%
87%
AOS
DDC
DDE
DDCMHT Baseline (n=45)
AOS
DDC
DDE
DDCMHT Follow-up (n=45)
4%
31%
69%
96%
MHOS
DDC
DDE
MHOS
DDC
DDE
DDCAT CHANGES BY DIMENSION (n=71)
Baseline
Follow-up
Dimensions
I. Program Structure
II. Program Milieu
III. Assessment
Mean (sd)
2.66 (1.06)
2.68 (0.56)
2.78 (0.65)
Mean (sd)
3.13 (0.95)
3.30 (0.75)
3.22 (0.65)
-5.48***
-8.99***
-9.07***
IV. Treatment
V. Continuity of care
VI. Staffing
2.35 (0.56)
2.61 (0.79)
2.90 (0.82)
2.72 (0.57)
2.97 (0.85)
3.21 (0.85)
-7.83***
-5.63***
-5.31***
VII. Training
Overall
2.30 (0.74)
2.61 (0.61)
2.78 (0.81)
3.04 (0.64)
-5.20***
-10.98***
***p<.001
t-value
DDCMHT CHANGES BY DIMENSION (n=45)
Dimensions
I. Program Structure
Baseline
Mean (sd)
2.73 (1.00)
Follow-up
Mean (sd)
3.52 (0.98)
-5.16***
II. Program Milieu
III. Assessment
IV. Treatment
V. Continuity of care
2.88 (0.85)
2.78 (0.47)
2.12 (0.45)
2.30 (0.78)
3.82 (0.72)
3.47 (0.47)
2.72 (0.50)
2.86 (0.56)
-8.56***
-8.21***
-9.10***
-6.24***
VI. Staffing
VII. Training
2.50 (0.64)
2.23 (0.60)
3.22 (0.70)
2.96 (0.88)
-7.70***
-6.15***
Overall
2.51 (0.55)
3.22 (0.56)
-9.17***
***p<.001
t-value
RESOURCES FOR QUALITY
IMPROVEMENT
• DDCAT Toolkit
http://dms.dartmouth.edu/prc/dual/pdf/ddcat_toolkit.pdf
Operational definitions for all 35 DDCAT benchmarks
and specific suggestions, with real examples, of how to
move from AOS to DDC or DDC to DDE scores
• Hazelden CDP Clinical Administrators Guidebook
http://www.hazelden.org/OA_HTML/ibeCCtpItmDspRte.jsp?i
tem=13480&sitex=10020:22372:US
Operational definitions for all of both the DDCAT and
DDCMHT items, practical suggestions, examples, and
actual tools for quality improvement
Sherry Larkins
Research Sociologist
Integrated Substance Abuse Programs
UCLA
(310) 267-5376
[email protected]