Supporting Individuals with Intellectual and Mental Health Needs

1. Supporting Individuals with Intellectual and Mental Health Needs A framework for Inter – Systems Collaboration Dr. Robert J. Fletcher Founder and CEO, NADD North Bay Regional Center March 8, 2012

2. Outline of Presentation • Barriers to Service Delivery • At the National Level : • Working Together or Not • Principles in Service Planning • A Framework to Promote Cross System • Collaboration

3. Dual Diagnosis Policy Issues The Typical Picture: Individuals with MI and ID are among the most challenging persons served by both MH and ID Service Delivery Systems Fletcher, 2008

4. Dual Diagnosis Policy Issues The Typical Picture: • Failure to plan services • Failure to fund flexible services • Failure to obtain technical assistance Fletcher, 2008

5. Dual Diagnosis Policy Issues The Typical Picture: • Failure to provide adequate training and technology transfer • Failure to share and assume joint responsibility • Failure to articulate a policy Fletcher, 2008

6. The Typical Picture: Dual Diagnosis Policy Issues • MH providers perceive that they do not have the skills to serve adults or children with a dual diagnosis • DD providers do not understand the services that the MH sector offers • MH providers do not understand the services that the DD sector offers Fletcher, 2008

7. Dual Diagnosis Policy Issues People with MI and ID typically require: • Professional staff with specialized clinical experience • Comprehensive service coordination • Presence of consistent backup support • Living requirements with fewer people NASDDS Survey, 2004

8. MH System Short term episodic treatment Focus on psychiatric needs Recovery model Local authority Medication Treatment Consumer/Client /Patient DD System Services/supports over lifetime Emphasis on direct support Self Determination State authority Behavioral Support (PBS) Self – Advocate/ Consumer Dual Diagnosis Policy Issues Little Collaboration Fletcher, 2008

9. Dual Diagnosis Principles • Co-occurring disorders should be treated as multiple primary disorders, in which each disorder receives specific and appropriate services. • Collaboration of appropriate services and supports must occur as needs are identified. Fletcher, 2008

10. Dual Diagnosis Principles • Service collaboration between systems is essential • Services provided to the individual are consistent with what the person wants and what supports are needed Fletcher, 2008

11. Dual Diagnosis Principles • Services are determined on the basis of comprehensive assessment of both MH and DD needs of each individual • Services are based on individual needs and not solely on either MH or ID diagnosis Fletcher, 2008

12. Dual Diagnosis Principles • Emphasize early identification and intervention • Involve the person and family as full partners • Coordinate at the system and service delivery level. Fletcher, 2008

13. Dual Diagnosis Principles • The whole system must be designed to be welcoming and accessible to people with co-occurring disorders • People with co-occurring disorders shall be supported in the least restrictive environment. Fletcher, 2008

14. Dual Diagnosis Principles • People with co-occurring disorders and their significant others, when appropriate, shall be empowered to make treatment decisions. • The system recognizes and values the long-term cost effectiveness of providing best practice services and supports for persons with co-occurring disorders. Fletcher, 2008

15. Working Together or Not In 65% of states, policy is developed in collaboration with other state agencies • Relationships with Corrections • 73% Not or not very effective • 22% Effective • 5% Very effective • Relationships with Mental Health • 55% Effective, very effective or extremely effective • 45% Not or not very effective NASDDDS, 2011

16. Working Together or Not Financial Operations • Operational authorities • State governments • Local counties and municipalities • Regional boards • Medicaid and Medicare funding • Medicaid covers 75% - 95% of costs for DD services, limited MH supports • Some potential under Medicare NASDDDS, 2011

17. Working Together or Not In general, . . . • MH has primary responsibility for psychiatric care • in 78% of states • DD has primary responsibility for long term support in 70% of states NASDDDS, 2011

18. Working Together or Not MH State Plan Services are available, But access is frequently difficult….. • MH programs are: • Under – funded • Stretched to the limit • Lack expertise to meet needs of people with ID / DD • Unable to bill for necessary activities • Include structural barriers NASDDDS, 2011

19. Working Together or Not Emergency Support and Response in 13 States • Mixed in 5 states (38%) • Usually MH but DD may support • Usually DD but MH may support • DD provides but MH contributes funding • DD exclusively in 5 of 13 states (38%) • MH exclusively in 3 of 13 states (24%) NASDDDS, 2011

20. Working Together or Not Top Barriers in 2010 • Availability of funding, targeted flexible dollars • Providers with sufficient expertise and interest • Access to appropriate psychiatric treatment and related services • Lack of trained staff MH and DD staff • Effective and timely crisis supports NASDDDS, 2011

21. Working Together or Not Effective Practice Elements The person-centered planning process must determine what is important TO the person and what is important FOR the person. - Michael Smull • Leadership • Commitment • Clear lines of authority • Independence • Protection • Commitment to collaboration • Focus on the Individual NASDDDS, 2011

22. Working Together or Not Essential Elements….. • Training • Coordination • Effective Staff • The right person • The right match • Build trust, dependability • Focus on the System • DD/MH interface Its not a matter of showing up – it is who shows up. It must be someone with commitment and interest in the individual. Someone who cares. - David Petonyak NASDDDS, 2011

23. Working Together or Not Effective Treatment • Timely Access to: • Appropriate psychiatric treatment and medication management • Positive Behavioral analysis and supports • Effective treatment strategies such as dialectical behavior therapy, EMDR, etc. • Community services, supports and resources • Employment and meaningful opportunities to participate in community life • Supports in home and with family NASDDDS, 2011

24. Working Together or Not Top New Initiatives and Good Ideas • Expanding Community Support Teams • Developing new psychiatric practice standards • Increasing DD expertise among MH • Establishing Centers for Excellence for training, leadership and technical assistance • Deinstitutionalization creates opportunities • Developing capacities through university programs • Cross-System Planning Formats • Strengthening crisis supports NASDDDS, 2011

25. A Framework To Promote Cross Systems Collaboration Cross Systems Task Force/Committee Fletcher - 2008

26. Cross Systems Collaboration Mission of a Dual Diagnosis Task Force/Committee A Cross System Task Force is a mechanism to draw attention to and make recommendations about, policy and services for individuals with ID and MH needs Fletcher, 2008

27. Cross Systems Collaboration • Purpose/Function of A Dual Diagnosis Task Force/Committee • Gather relevant data/formation • Identify strengths in service delivery systems • Identify challenges in service delivery system Fletcher, 2008

28. Cross Systems Collaboration • Purpose/Function of A Dual Diagnosis Task Force/Committee • Generate options for improvement in service delivery systems • Promote cross systems education/training to enhance staff competencies • Advocate for policy initiative that advance cross systems collaboration Fletcher, 2008

29. Cross Systems Collaboration • Composition Of A Dual Diagnosis Task Force/Committee • Representatives from Mental Health Departments • Representatives from ID/DD Departments • Representatives from provider agencies • Family/consumer/advocate representatives Fletcher, 2008

30. Cross Systems Collaboration Stakeholders from other than MH & IDD systems could be included as appropriate, perhaps on an “as needed” basis. These include, but are not limited to representatives from: Fletcher, 2008

31. Five Aspects Of A Coordinated Care System • Collaboration • Comprehensiveness • Flexibility • Continuity • Leadership and Partnership Adapted from Kline, et al, 1993

32. Coordinated Care System • Service Collaboration: • Policy level – linkage • Program level – integrated • Individual level – person-centered coordination Adapted from Kine, et al, 1993

33. Coordinated Care System • Comprehensiveness No One System Can Serve All People with MH/ID Mental Health Education MH/DD Social Services Child & Family Substance Abuse Health Criminal Justice Adapted from Kine, et al, 1993

34. Coordinated Care System Substance Abuse Mental Health Child & Family Serv. Criminal Justice Vocational PERSON Health Education MR-DD Housing Social Serv. Fletcher, 2007

35. Coordinated Care System 3. Flexibility Flexible Enough to Modify Traditional Approaches Sufficient flexibility for: • increase time/resources in assessments • cross training • modification of traditional approaches Adapted from Kine, et al, 1993

36. Coordinated Care System 4. Continuity Keep an eye on: • changing needs • changing systems • propensity for behavioral problems • need for long term treatment & supports • need to focus on multiple systems in different contexts over a life span Adapted from Kine, et al, 1993

37. Coordinated Care System 5. Leadership and Partnership • Partnership across systems • Need leadership to facilitate coordination • Ensure accountability • Political will Adapted from Kine, et al, 1993

38. Other Policy Recommendations • Other Important Aspects of Policy Development: • Children and Adolescent Issues • Cross Systems Training • Cross Systems Crisis Intervention Service • Consultation and Treatment • Cross System Coordination: State/Local Level US HHS, 2005

39. Train teachers, other professionals, and parents to recognize signs and symptoms of ED in children with ID • Improve transitional planning from school to adult systems system operations: Children & Adolescent Issues Fletcher, 2007

40. Need Cross-Systems Training • Mutual understanding of different culture, language and philosophy • Acquire knowledge regarding how the other system operations: - eligibility - funding - assessment - structure • Learn how habititative/treatment strategies are different from one system to another Training Issues Fletcher, 2008

41. Crises Intervention Service • A Cross System Approach • Provide short term crisis intervention with the goal of minimizing a need for hospitalization, crisis residential care or out-of-home placement • Staff from crisis service interacts with all appropriate systems Fletcher, 2008

42. Bio-Psycho social model in assessment • Rationale psychopharmacology • Integrating mental health treatment with behavioral approaches • Effective cross-systems transitional services • Modifying individual and group therapy Consultation & Treatment Issues Fletcher, 2008

43. State and Local • Planning and coordination at local level • Planning and coordination at state level • Planning and coordination between local and state level Cross Systems Planning & Coordination Fletcher, 2008

44. Treat Collaboration as Seriously as You Do Your Budget If you need expert assistance to forge collaboration, get it!

45. Service Planning and Policy • Plan cross systems services strategically • Design flexible service models that can change over time as individual needs change • Obtain technical assistance • Provide cross systems training to enhance agency and practitioner competencies • Provide incentives for assuming and sharing responsibility J. Jacobson, 2003

46. Collaboration Strategies • Identify and clearly state specific purposes for collaboration • Allow time to consider all provisions, so that final decisions will be more fully supported • Negotiate written agreements for organizational responsibilities, program design, fiscal arrangements, and established time frames Ament, 1987

47. Collaboration Means Sharing Resources and Authority Make sure that each organization understands what it brings to the collaboration and reach a middle ground.

48. ID/MI Discussion Matrix

49. ID/MI Action Plan

50. THANK YOU! For more information, please contact: Dr. Robert J. Fletcher NADD 132 Fair Street, Kingston, NY 12401 Telephone: 845-331-4336 E-mail: rfletcher@thenadd.org Web site: www.thenadd.org