CMHA Ottawa: Integrated Treatment for Individuals with Co-occurring Mental Health and Substance Use Disorders

1. 1 CMHA Ottawa: Integrated Treatment for Individuals with Co-occurring Mental Health and Substance Use Disorders Donna Pettey MSW RSW Director of Operations November 22nd 2006

2. 2 Who is CMHA Ottawa? Founded in 1953 >$10 Million Budget/100+ employees Funding from: Province of Ontario, City of Ottawa, United Way, & private donations Three primary areas of work: Public education Social Action Direct Service Our agency has experienced tremendous growth and expansion over the past several years…..as we have increased not only our capacity to serve more clients, but to provide an increasing menu of services to those clients, we have struggled to develop an approach that provides for an integration of services. We want to talk today a little bit about this journey that we have been on, what we have learned along the way and hopefully, communicate to you, that it is completely possible to work with individuals with very challenging needs (for us, primarily homeless with concurrent disorders), and to improve the quality of life for clients through the provision of an integrated service approach.Our agency has experienced tremendous growth and expansion over the past several years…..as we have increased not only our capacity to serve more clients, but to provide an increasing menu of services to those clients, we have struggled to develop an approach that provides for an integration of services. We want to talk today a little bit about this journey that we have been on, what we have learned along the way and hopefully, communicate to you, that it is completely possible to work with individuals with very challenging needs (for us, primarily homeless with concurrent disorders), and to improve the quality of life for clients through the provision of an integrated service approach.

3. 3 CMHA Ottawa:  Research and Evaluation Partnerships with the University of Ottawa Centre for Research on Community Services CMHEI Concurrent Disorders (SCPI) Hospital Outreach program SEEI Court Support Services (Upcoming) Forensic Out-patient Evaluation Research informs CMHA Services, Provincial Mental Health system and Knowledge Transfer for the Field

4. 4 Why is CMHA in the business of Providing Integrated Treatment?

5. 5 Development of Integrated Treatment Capacity: Why is this a priority? Prevalence rates of Substance Use Disorders in persons with severe mental illness: Life time prevalence: 40%-60% Recent (past 6 months): 25%-35% For us @ CMHA, yesterday (Thursday May 5th 2005) we had 457 clients active (being served by case management (201), CTO (19), Hospital Outreach (113), Housing Outreach 68, Court Outreach 31, Youth Outreach 16 and Youth CD (9): That translates into 114-160 clients @ CMHA today, here, now, with a concurrent disorder requiring treatment and support. (With 183-274 at a life time prevalence of developing a CD).For us @ CMHA, yesterday (Thursday May 5th 2005) we had 457 clients active (being served by case management (201), CTO (19), Hospital Outreach (113), Housing Outreach 68, Court Outreach 31, Youth Outreach 16 and Youth CD (9): That translates into 114-160 clients @ CMHA today, here, now, with a concurrent disorder requiring treatment and support. (With 183-274 at a life time prevalence of developing a CD).

6. 6 CMHA REFERRAL GUIDELINES Clients must have a serious mental illness, as defined by the Ministry of Health (Diagnosis, Disability, Duration) Clients referred through the Provincial Court House must be in conflict with the law Clients referred through the Hospital Outreach service must be patients who are about to be discharged from in-patient psychiatry beds and/or clients will have multiple problematic ER presentations

7. 7 REFERRAL GUIDELINES Clients must be homeless or at imminent risk of becoming homeless. This means that the person is living in unstable housing, is engaging in behaviour that puts their housing at risk and/or where an eviction order could be served. Clients with multiple and complex needs and as a result are not able to formulate and/or implement their own community support plan without intensive support will be priorized

8. 8 MULTIPLE AND COMPLEX NEEDS An individual with multiple and complex needs is defined as a person who meets the criteria for serious mental illness, has had past episodes of aggressive or violent behaviour, and has one or more of the following characteristics, including: Psychotic symptoms that include feeling threatened, under control of outside forces and increased hostility; Three or more psychiatric hospital admissions within the last 2 years or has been detained in an inpatient facility for 60 or more days with this period Subject of two or more police complaints/interventions within the last12 months or has been incarcerated in a correctional facility for 30 or more days within this period Recently evicted from housing or is homeless or living in shelters Current problems with drugs and/or alcohol; and/or Problems following-up with recommended treatment plans

9. 9 Link between homelessness, mental illness, and concurrent disorders is well documented: 30-35 % of the homeless in general, and up to 75% of homeless women specifically, have a mental illness[1] 20-25% of homeless people suffer from concurrent disorders (severe mental illness and addictions)[2] In Ontario, 6,100 people sleep in shelters every night[3] - out of these 2,013 have a mental illness, and 1,220 have an additional concurrent disorder [1] City o f Toronto (1999), January). Taking responsibility for homelessness: An Action plan for Toronto. Report of the Mayor’s Homelessness Action Task Force. Retrieved January 31, 2003 from www.city.toronto.on.ca [2] Golden, A. (2000). Mental health and homelessness. The 69th Annual Couchiching Conference-The Future of Health in Canada: The Art of the Possible. [3] Statistics Canada. (2002, November). 2001 census: Collective dwellings. Retrieved January 31st 2003 from www.statcan.ca

10. 10 Link between homelessness, mental illness, and concurrent disorders is well documented: In 1998 CMHA Ottawa Branch conducted a survey of homeless clients with mental illness where 38% reported taking drugs more than 12 times a week and 39% reported regularly drinking more than 12 times a week Prevalence rates of substance use disorder amongst individuals with serious mental illness ranges from 20% to 80%.

11. 11 Impact of Substance Abuse on Psychiatric Illness? Effects are additive………. Relapse and re-hospitalizations In severity of depression symptoms related to Alcohol consumption Suicide risk Family / interpersonal conflict Financial problems Risk of violence/aggression (perpetrator and/or victim)

12. 12 Impact of Substance Abuse on Psychiatric Illness? Effects are additive………. ?risk of homelessness/housing problems ?legal problems ?risk of severe physical health problems Worsens psychiatric outcomes and social functions The argument becomes quite compelling that as providers of community mental health programmes, in particular programmes serving those with serious mental illness, the most vulnerable to many of these consequences, we absolutely must find ways and means to provide treatment… As a provider of mental health services, we certainly found that our clients experienced, do experience many of these consequences so when we began to consider .. The argument becomes quite compelling that as providers of community mental health programmes, in particular programmes serving those with serious mental illness, the most vulnerable to many of these consequences, we absolutely must find ways and means to provide treatment… As a provider of mental health services, we certainly found that our clients experienced, do experience many of these consequences so when we began to consider ..

13. 13 Integrated Treatment:  What is it?

14. 14 Components of Integrated Treatment & How They Work Together Integration of services Comprehensive Assertive Reduction of negative consequences Long term perspective Motivational based treatment Multiple psychotherapeutic modalities Integration of services = services that incorporate treatment for both the mental illness and the substance use disorder simultaneously by the same clinicians, ideally within the same organization, but at the very least for a coordinated treatment plan (core value of shared decision making and development of a collaborative relationship with the client) Comprehensive= ability to address all life domains of needs: housing, financial, education, work…….NOT JUST substance abuse issues (an issue that in fact the client may have no initial issue in addressing) Assertive = going to where the client is and investing in engagement….you do not wait for the client to knock on your door treatment ready Reduction of negative consequences=harm reduction approach (has both philosophical and practical dimensions) Long term perspective=time unlimited services…..this is a long term commitment to making significant changes in people s lives Motivational based treatment=incorporating notion of stages of changes and calibrating recovery in accordance with where a particular client is at……(tapping into the clients motivation for change Multiple psychotherapeutic modalities = have as many tricks up your sleeve as possible: individual support, group treatment…… and a variety of group options….groups related specifically to addressing substance use, but also social skills groups, vocational support, illness management groups, family support, etc.Integration of services = services that incorporate treatment for both the mental illness and the substance use disorder simultaneously by the same clinicians, ideally within the same organization, but at the very least for a coordinated treatment plan (core value of shared decision making and development of a collaborative relationship with the client) Comprehensive= ability to address all life domains of needs: housing, financial, education, work…….NOT JUST substance abuse issues (an issue that in fact the client may have no initial issue in addressing) Assertive = going to where the client is and investing in engagement….you do not wait for the client to knock on your door treatment ready Reduction of negative consequences=harm reduction approach (has both philosophical and practical dimensions) Long term perspective=time unlimited services…..this is a long term commitment to making significant changes in people s lives Motivational based treatment=incorporating notion of stages of changes and calibrating recovery in accordance with where a particular client is at……(tapping into the clients motivation for change Multiple psychotherapeutic modalities = have as many tricks up your sleeve as possible: individual support, group treatment…… and a variety of group options….groups related specifically to addressing substance use, but also social skills groups, vocational support, illness management groups, family support, etc.

15. 15 Integrated Treatment For Individuals with Co-occurring Mental Health and Substance Use Disorders Components of Integrated Treatment Integration of services Comprehensive Assertive Reduction of negative consequences Long term perspective Motivational based treatment Multiple psychotherapeutic modalities

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18. 18 CMHA Housing

19. 19 Our Housing Philosophy Our Principles of Providing Choice in Housing (from Carling): Individuals choose their own living situation (informed and meaningful choice) Individuals live in regular, stable housing; not in “programs” Individuals have access to services and supports that enable them to succeed in the living situation These supports are: Flexible Portable Available when the person wants them

20. 20 Housing Portfolio: 92 units Approx. 70 units are Special Referral Agreements with Non-Profit Housing Providers and For-Profit Landlords 23 units with City Living (now Ottawa Community Housing) 20 units with CCOC 27 units with Private For-Profit Landlords All the units are self-contained and scattered, except 6 units that are in a designated building, of which 4 are semi-bachelor, not entirely self-contained Many of the units have been occupied since 2000 Program grew gradually from 0 to 70 units over the period 2000 to 2003

21. 21 Housing Portfolio: 92 units 22 units are condominiums CMHA purchased with Ministry of Health and Long-Term Care Homelessness Initiatives dollars 2.2 million dollars capital expenditure (approx. 100,000 per unit) Only owner-occupied Require rent supplements from City of Ottawa to operate Located across the city, easy access to buses Most with amenities: some with swimming pool, in-unit laundry, exercise room, one with Jacuzzi Some units occupied since July 2003 Units have been added gradually over the period July 2003 to April 2004

22. 22 Who are the Clients in the Housing Units? -- Gender

23. 23 Clients in the Housing Units – Primary Diagnosis

24. 24 Clients in the Housing Units – Income Source (condos)

25. 25 Clients in the Housing Units – Income Source (Agreements)

26. 26 Clients in the Housing Units – Addiction Issues

27. 27 Clients in the Housing Units – Previous Housing

28. 28 Outcomes: Housing Tenure / Turnover and Vacancy Condo Units: 25 clients have occupied the 22 units so far Referral Agreement Units: from January to December 2003: Avg of 68.4 units per month 1.5% turnover 0.4% vacancy CCOC units: of 14 units that are not congregate living, 13 of the tenants are the original tenants, many dating back to 2000

29. 29 Summary Must tie in with/ stem from: Research Practice Agency Values Consumer Preference

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