Center for Excellence in Integrated Care (CEIC) Getting to Capable: Status of New York's OMH and OASAS Outpatient Servi

1. Center for Excellence in Integrated Care (CEIC) Getting to Capable: Status of New York's OMH and OASAS Outpatient Services in Providing Integrated Care Stanley Sacks, PHD, CIRP, NDRI, New York, NYMichael Chaple, PHD, CIRP, NDRI, New York, NY ChackuMathai, CPRP, NYAPRS, Albany, NY presentation to — NYAPRS 29th Annual Conference, “Bringing Recovery Home for All,” September 14-16, 2011, Hudson Valley Resort and Conference Center, Kerhonkson, NY

2. What is CEIC’s purpose? Fosters the implementation of integrated care in screening, assessment, and evidence-based interventions for New York State (NYS) residents with co-occurring conditions and facilitates OMH and OASAS initiatives in this area

3. Timeline New York State (NYS) Office of Alcoholism & Substance Abuse Services (OASAS) and Office of Mental Health (OMH) convene a Co-occurring Disorders (COD) Task Force (2007) May, 2007 The NYS COD Task force makes recommendations December, 2007 The Directors of licensed substance abuse and mental health programs receive two letters with recommendations for integrating services for COD from the Commissioners of OASAS and OMH June 20 & July 31, 2008 The New York State Health Foundation (NYSHealth) funds the Center for Excellence in Integrated Care (CEIC, pronounced “seek”) November 1, 2008

4. What does CEIC do? Provides technical assistance (hands-on, intensive, and longitudinal) • Engages Leadership • Performs on-site assessments • Presents site reports • Conducts provider forums • Builds collaborations and informal networks • Holds Peer Recovery Workshops • Supplies ongoing support, guidance, and consultation • Links programs to resources, such as FIT, TIP 42, and related in-service training, as well as other trainings and curricula

5. CEIC Assessment Methods • Uses DDCA[MH]T (Dual Disorder Capability in Addiction Treatment and Dual Disorder Capability in Mental Health Treatment) • Samples individual clinics within regions • Employs direct onsite observation • Scores and reports on 7 domains and overall • Makes specific recommendations to raise capability

6. Improving Co-occurring Capability Recommendations by DDCA[MH]T Dimensions

7. Dual Disorder Capability Enhanced (N=300) Transformation of the Service System may be said to occur when the majority of outpatient clinics are rated capable or above 3.09 3.06 Capable 2.70 2.76 2.50 2.53 2.47 2.48 Basic Program Structure Program Milieu Staffing Training Treatment Continuity of Care Assessment Total Score Scores based on DDCA[MH]T = Dual Diagnosis Capability in addiction [Mental Health] Treatment Index

8. Program Structure Recommendations • Update agency mission statement (or develop a program service statement) to reflect that co-occurring services are provided • Ensure that the program’s licensure agreement (or state permit) identifies the target population as individuals with substance related disorders (for addiction clinics) or mental health disorders (for mental health clinics) but does not restrict the program from treating individuals with co-occurring mental disorders or substance use disorders, respectively • Demonstrate that your program’s system of care meets the definition of collaboration; that is, shared responsibility for treating a person with co-occurring conditions, involving regular and planned communication, and shared progress reports or memoranda of agreement Enhanced – Capable – 2.48 Basic – Program Structure

9. Program Milieu Recommendations DDCA[MH]T Score • Expect and welcome clients with both disorders • Ensure that materials for both substance related and mental disorders are posted and distributed • Engage in a discussion with staff regarding "attitudes and values" towards treatment of co-occurring disorder Enhanced – Capable – 2.50 Basic –

10. Clinical Process — Screening (one item from Assessment Domain) Recommendations • Implement one of the state-recommended standardized screening instruments (these are all free, brief, and do not require clinical expertise to administer) • Establish a protocol that will direct all those with a positive score on the screen to an integrated assessment • Separate the screen from the assessment protocol; the screen should drive the assessment, but it is not a diagnostic evaluation nor should it be used to determine severity of a mental health or substance use condition Enhanced – Capable – 3.24 Basic –

11. Clinical Process — Assessment Recommendations • Provide a comprehensive assessment that covers all 12 recommended domains and includes a thorough substance use and mental health evaluation • Obtain diagnostic evaluation as part of the assessment process • Build on the stages of change for both disorders • Synthesize assessment information into main problem areas that need to be addressed • Use assessment data to inform the treatment plan Enhanced – Capable – 3.06 Basic –

12. Clinical Process — Treatment • Integrated COD Services Recommendations • Allow the free expression and discussion of co-occurring problems in group and individual sessions • Ensure inclusion of mental health and substance use content in all groups • Create a “home” for co-occurring disorders in the treatment schedule (i.e., offer a psycho-educational class for COD and a dual recovery group) • Provide supervision and coaching to increase staff competency in COD Enhanced – Capable – 2.53 Basic – Treatment: Integrated COD Services

13. Clinical Process — Treatment • Evidence Based Interventions Recommendations • Organize treatment with a stage-wise approach • Build staff competencies in Motivational Interviewing • Employ existing trauma curriculums; for example, Seeking Safety and Trauma Recovery & Empowerment Model (TREM) • Offer Wellness Self-Management curriculum to integrate co-occurring content further • Gradually introduce other NYS recommended evidence-based interventions 24% Evidence-based Interventions

14. Continuity of Care Recommendations • Ensure that the discharge plans address both the substance use and mental health disorders • Encourage and arrange connections to community support groups during treatment and as part of discharge planning (e.g. Double Trouble in Recovery, Dual Recovery Anonymous) • Provide a supply of medication sufficient to span from discharge until continuing treatment has been established Enhanced – Capable – 2.76 Basic –

15. Staffing Recommendations • Ensure that at least one direct care staff member has mental health and substance use competency or licensure • Provide on–site clinical supervision sessions that include a focus on co-occurring disorders • Ensure that team meetings and case reviews incorporate co-occurring disorders Enhanced – Capable – 3.09 Basic –

16. Training Recommendation • Demonstrate that the program has a written training plan • Maintain and enhance staff competencies in co-occurring services using up-to-date literature, films, and other media, as well as in-service and external trainings • Train staff in specialized treatment approaches and pharmacotherapy Enhanced – Capable – 2.47 Basic –

17. Training —Focus on Integrated Treatment Recommendation • Urge staff to enroll in FIT (Focus on Integrated Treatment) online learning Description of FIT • This training helps practitioners gain a firm foundation in evidence-based integrated treatment for COD including screening and assessment, stage-wise treatment, motivational interviewing, and more. Additional modules help clinical supervisors develop their supervision skills and guide agency leaders through changes to ensure sustainability of integrated treatment. • Along with learning modules, CPI (the Center for Practice Innovation) offers inline implementations supports through webinars, “Ask the Expert” forums, and discussion threads. • The training is comprised of 35 individual modules developed alongside experts at the Dartmouth Psychiatric Research Center http://www.practiceinnovations.org/CPIInitiatives/FocusonIntegragedTreatmentFIT/tabid/99/Default.asp

18. Training — TIP 42 Recommendation • Refer to and use TIP 42 and its associatedin-service training curriculum Description of TIP 42 • Introduction • Definitions, Terms, & Classification • Systems for COD • Keys to Successful Programming • Assessment • Strategies for Working with Clients with COD • Traditional Settings & Models • Special Settings & Models • Special Settings & Specific Populations • A Brief Overview of Specific Mental Disorders & Cross-Cutting Issues • Substance-Induced Disorders • http://store.samhsa.gov/product/SMA08-3992

19. Improving Co-occurring Capability — Quick Guide 10 recommendations for Getting to “Capable” Provide educational material for both disorders Revise agency mission statement or develop a program service statement Implement one of the NYS-recommended standardized screening instruments Use assessment data to inform the treatment plan Allow co-occurring concerns to be expressed and discussed in all group and individual sessions Ensure that all groups include mental health and substance use content Offer a psycho-educational class on COD and a dual recovery group to create a “home” for co-occurring disorders in the program schedule Include both substance use and mental health treatment in discharge plans and provide sufficient medication to last until continuing care has been established Urge staff to enroll in FIT web-based learning Refer to and use TIP 42 and its associated training curriculum Easy to Employ & Conserves Resources

20. Improving Co-occurring Capability – Quick Guide Clinic Name: Your Name: Email: Phone: 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ Program Structure 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ Program Milieu 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ Clinical Process: Screening & Assessment 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ Clinical Process: Treatment 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ Continuity of Care 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ Staffing 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ Training

21. Evidence-based Interventions Screening Instruments Assessment Domains • For both disorders: • Approved medications • For substance use disorders: • Evidence-based individual, group, couples, and family treatments –including • motivational enhancement • CBT • 12-step facilitation • behavioral couples & family therapy • contingency management • For mental illness: • CBT, medication • For serious mental illness: • Managing illness (IDDT, education, medication, CBT) family psychoeducation, supported employment, social skills training • Peer support • For mental disorders: • Modified MINI Screen (MMS) • Mental Health Screening Form III (MHSF III) • K6 Screening Scale (K6) • For substance use disorders: • Modified Simple Screening Instrument for Substance Abuse(MSSI-SA) • CAGE Adapted to Include Drugs (CAGE-AID) • Alcohol, Smoking, and Substance Involvement Screening Test – v3(ASSIST v3) • Presenting problem[s] • Current symptoms & functioning • Background • Individual history • Substance use • Mental health • Medical history • Mental status examination • Client perception[s] • Cultural and linguistic considerations • Supports & strengths • Diagnostic impressions on 5 DSM Axes Taskforce and Commissioners’ Recommendations

22. Training & Technical Assistance ActivitiesYear 1,Year 2, Year 3(4th Quarter of Year 3 is projected) 250 200 150 100 50 0 Year 1 (Nov ’08 - Dec ’09) Year 2 (Nov ’09 - Oct ’10) Year 3 (Nov ’10 – Oct ’11) 11 200 165 8 5 5 4 4 86 3 3 0 451 DDCA[MH]T assessments 7 Bldg RecoveryWorkshops 14 LeadershipForums 22 Bldg Capability Forums DDCA[MH]T = Dual Diagnosis Capability in Addiction [Mental Health] Treatment Index

23. CEIC TA Serviceshave been provided in about ¾ of the state’s regions/counties

24. Dual Disorder Capability Enhanced (N=300) Closer to Capable than to Basic 3.09 3.06 Capable 2.70 2.76 2.50 2.53 2.47 2.48 Basic Program Structure Program Milieu Staffing Training Treatment Continuity of Care Assessment Total Score Scores based on DDCA[MH]T = Dual Diagnosis Capability in addiction [Mental Health] Treatment Index

25. Dual Disorder Capability— Percentage Capable Enhanced 5 7% 4.5 4 43% are near or above Capable 3.5 21% Capable 3 15% 22% 2.5 30% 2 6% 1.5 Basic 1 Scores based on DDCA[MH]T = Dual Diagnosis Capability in Addiction [Mental Health] Treatment Index

26. Bi-annual OASAS EBP Survey • Surveydesigned to obtain EBP integration by implementation stages (Fixsen et al.) • Added items on COD in collaboration with CEIC (and NKI) to assess COD practices • Sent to all OASAS certified programs • Rated on a 5- point implementation scale 5. Sustainability 4. Innovation 3. Implementation 2. Installation 1. Exploration • Employs drop-down menu of additional questions to increase the accuracy of reporting • Response rate 96% of all licensed programs

27. Local Services Plan (LSP) Survey Tool(sample page)

28. Evidence-Based Practices and Evidence-Based Interventions: Level of Implementation Level of Implementation Scale: 5 = Sustainability 4 = Innovation 3 = Implementation 2 = Installation 1 = Exploration 0 = Not applicable (hasn’t moved to implement at all) Practices Interventions

29. Screening, Assessment, Integrated ServicesBased on OASAS Survey (Level 5)

30. Evidence-Based Treatment for CODBased on OASAS Survey (Level 5) About ¼regularly employ evidence-based interventions 23% Cognitive Behavioral Therapy Behavioral Couples Therapy Total Motivational Interviewing Contingency Management Mutual Self-help

31. Comparative Survey Results

32. Strategic Plan — Reach & Penetration The strategic plan to reach & penetrate more than 1,000 out-patient substance abuse & mental health clinics over 4 years Direct (“hands-on”) Technical Assistance • DRCs • FIT • Regional / County Networks amplifies Direct TA and promotes Sustainability

33. Evaluation PlanHow will we know the system status? Follow up DDCA[MH]T survey on representative sample Follow up on OASAS survey — planned for 2012 Analysis combining these data sources (as briefly illustrated here) Focus groups Case studies Brief web-based survey

34. Recent Developments Integrated Services – Nassau County to integrate services both within clinics and across the service system Video – creating a video on building COD capability in the areas of Screening, Assessment and Evidence-Based Practices called “Getting to Capable” Manuscript – writing a descriptive study of the current status of the system for publication New Instrument – developing and refining an instrument to measure recovery-oriented services integration with NYAPRS New Instrument – developing and field testing an instrument withDr. Mark McGovern to measure the degree to which primary health care services have been integrated with mental health and substance use interventions. This has particular significance for health care reform.

35. Summary • There exists a clear and increasingly positive picture of the status of OMH and OASAS outpatient clinics regarding evidence based practices and interventions • 45% for screening • 40% for assessment • ⅓ for integrated services • ¼ for evidence based interventions • The potential for advancement is greatest in the domains of Program Structure, Milieu, Treatment, Training and Continuity of Care, areas where certain improvements are considered to be fairly easy to achieve given the current status of staffing and resources • Transformation of the Service System may be said to occur when the majority of outpatient clinics are rated capable or above OMH and OASAS outpatient clinics are moving toward a COD capable status

36. Conclusion • The project is significant in its: • Promise of improving the health of NYS residents with co-occurring conditions • Potential to reduce health disparities • Ability to inform allocation of resources • Capacity to effect system transformation in the delivery of services • Implications for health care reform: • Identifying capable programs • Illustrating methods and approaches for advancing integration

37. Contact Information Stanley Sacks, PhD, Director Center for the Integration of Research & Practice (CIRP) & Center for Excellence in Integrated Care (CEIC)National Development & Research Institutes, Inc. (NDRI)71 W 23rd Street, 8th FloorNew York, NY 10010TF 877.888.6677 tel 212.845.4400  fax 212.845.4650www.nyshealth-ceic.orgwww.ndri.org Michael Chaple, PhD, Deputy Director Center for the Integration of Research & Practice (CIRP) & Center for Excellence in Integrated Care (CEIC)National Development & Research Institutes, Inc. (NDRI)71 W 23rd Street, 8th FloorNew York, NY 10010TF 877.888.6677 tel 212.845.4400  fax 212.845.4650www.nyshealth-ceic.orgwww.ndri.org ChackuMathai, CPRP, Associate Executive Director New York Association of Psychiatric Rehabilitation Services1 Columbia Place, 2nd FloorAlbany, NY 12207tel 518.436.0008 www.nyaprs.org CEICreceives support (awards 2008-2496857 & 2009-3426912) from the New York State Health Foundation