Integrated Dual Diagnosis Services: Implementation and Program Maintenance

1. Integrated Dual Diagnosis Services:Implementation and Program Maintenance Randi Tolliver, PhD, CADC Illinois Co-Occurring Center for Excellence www.illinoiscoce.org

2. 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”

3. Integrated Dual Diagnosis Services • Improve quality of life • Promote hopeful interactions • Utilize biopsychosocial treatments • Promote consumer and family involvement in service delivery • Promote and increase stable housing

4. Integrated Dual Diagnosis Services • Promote a recovery concept • Utilize Recovery Management and/or Recovery Support Specialists • Increase continuity of care • Promote employment as an expectation • Increase independent living

5. Integrated Dual Diagnosis Services • Co-morbidity is an expectation, not an exception. • There is no one type of dual diagnosis program or intervention. • Motivational enhancement strategies • Substance abuse and mental health counseling services

6. Integrated Dual Diagnosis Services • Multidisciplinary teams • Access to comprehensive services • Participation in self-help groups • Pharmacological treatments • Interventions to promote health and well-being

7. Evidence-Based Practice Two Directions in EBP • Evidence-Based Interventions: • EB Guidelines, EB Practices, Empirically- supported (validated) Treatments • Evidence-Based Process for decision-making: • EB Process, EB Individual Practice

8. Evidence-Based Guidelines(EBG) • Different methods for designing guidelines: global subjective judgment or consensus-based, outcomes based, preference based, expert opinion, evidence based • Importance of explicit, evidence-based process in developing guidelines

9. 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).

10. 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

11. 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

12. 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

13. 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.

14. 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.

15. ROSC System of Care Elements • 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.

16. ROSC System of Care Elements • 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.

17. Comprehensive, Continuous, Integrated Systems of Care Model (CCISC) • 4 Basic Characteristics • 8 Principles of Treatment • 12 Steps of Implementation • Kenneth Minkoff, MD

18. 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

19. 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

20. 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

21. Twelve Steps of Implementation of CCISC 1. Integrated system planning process 2. Formal consensus on CCISC model 3. Formal consensus on funding the CCISC model 4. Identification of priority populations, and locus of responsibility for each 5. Development and implementation of program standards 6. Structures for intersystem and interprogram care coordination • Kenneth Minkoff, MD

22. 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

23. Organizational Environment Common ground: • Values and principles • Guidelines • Outcome measures Differences: • Treatment philosophy • Treatment practice • Relationships • Vocabulary • Basic competencies

24. Organizational Change • Understanding the organization’s model • Multi-level organizations • Mutual and conflicting needs • Traditional versus innovative ways of communicating • Systems tend to resist substantial change Adapted from Hendrickson, E. L (2006)

25. 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.

26. Program Development • Utilize evidence-based or best practices • Utilize a competency-based perspective • Employ recovery support specialists • Develop a plan to address housing needs • Employ employment specialists

27. Program Development • Develop policy & procedures for program operations • Develop a clear understanding of target population and program goals • Develop a marketing strategy that will ensure adequate numbers of consumers are engaged

28. Program Development • Develop a realistic time frame for hiring and training staff • Establish a functional and clear admission and referral process • Allow easy accessibility to program services across the continuum of care

29. Questions to Consider for Development and Implementation • Currently, which co-occurring treatment services are being offered to which consumers? • Where in the continuum of care are the services being offered? • Do current services demonstrate the qualities of “effective” services? • Do the services meet the needs of the community? SAMHSA Tip 42

30. Questions to Consider • What resources are available? • What are the barriers to implementing the EBP? • What are the priorities? • What is the capacity of the agency to implement comprehensive, integrated services?

31. Questions to Consider • What are the core competencies needed for staff to provide effective services? • What services are currently offered? • What modifications will need to be made in the evidence based practice?

32. Implementation Challenges • Physician or psychiatrist staffing • Physical resources • Billing and reimbursement issues McGovern, Xie, et. al. (2006).

33. Implementation Challenges • Identifying and responding to gaps in workforce competencies, certifications, and licensure • Addressing increases in staff concern related to changes in roles and responsibilities • Addressing discrepancies in record keeping

34. Implementation Challenges • Addressing organizational structure and policies • Resolving differences in treatment philosophies • Establishing a cohesive multidisciplinary team

35. 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.

36. 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)

37. General Organizational Index • 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

38. IDDT Fidelity Scale • 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

39. Dual Diagnosis Capability in Addiction Treatment(DDCAT) Index • Program Structure • Program Milieu • Clinical Process: Assessment • Clinical Process: Treatment • Continuity of Care • Staffing • Training McGovern et al. (2006).

40. 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.

41. Motivational Interviewing Fidelity • Training Protocol • 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).

42. 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)

43. 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)

44. Implementation Index • Organizational and Contextual Factors • Implementation Strategies • Program Culture • Staffing & Training • Evaluation • Other Implementation Activities McGovern et al. (2006).

45. Paradigm Shifts Interactive Staff Training Focus is on the team rather than the individual Goal is the development of a user-friendly program

46. Interactive Staff Training • Work with team members from several teams. • Meet with team on site. • Meet monthly for one hour. • 1 year commitment.

47. 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

48. 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.

49. 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 co-occurring disorders: Prevalence estimates, treatment practices, and barriers. Journal of Substance Abuse Treatment (31), 276-275.

50. 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.