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State Initiatives on Dual Disorders . Presented by Lenore A. Kola, Ph.D., Co-Director Patrick E. Boyle, MSSA, LISW, LICDC Director of Clinical Training And Barbara Wieder, PhD Director, Evidence Based Practice Implementation Project the Ohio SAMI CCOE is a partnership between

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state initiatives on dual disorders

State Initiatives on Dual Disorders

Presented by

Lenore A. Kola, Ph.D., Co-Director

Patrick E. Boyle, MSSA, LISW, LICDC

Director of Clinical Training

And

Barbara Wieder, PhD

Director, Evidence Based Practice

Implementation Project

the Ohio SAMI CCOE is a partnership between

the Mandel School of Applied Social Sciences and

the Dept of Psychiatry, CASE School of Medicine,

Case Western Reserve University

in collaboration with the Ohio Departments of

Mental Health and Alcohol and Drug Addiction Services

May 6, 2005

slide2

Treatment

Strategies

Clinical Practice

and the

Community

As we strengthen our knowledge on treatment of dual disorders and supported employment, it becomes increasingly urgent to expand our research on evidence based practice on to strategies to optimize their translation into clinical practice and the community

State Initiatives on Dual Disorders

bridging the gap between research and practice
Bridging the Gap Between Research and Practice
  • Assuring that technology transfer actually occurs – using evidence based treatment models such as the Integrated Dual Disorder Treatment Model and Supported Employment Model
  • Using more effective dissemination and training strategies
  • Involve community treatment providers in both practice and research

State Initiatives on Dual Disorders

introduction
Introduction
  • People with serious mental illness can recover and work
  • People are much more likely to recover if they have access to IDDT
  • People are much more likely to work if they have access to Supported Employment
  • Implementation requires thoughtful planning and sustained efforts

State Initiatives on Dual Disorders

integrated dual disorders treatment iddt what is it
Integrated Dual Disorders Treatment - IDDT: What is it?
  • The New Hampshire-Dartmouth Model
  • Robert Drake, MD and colleagues
  • Treatment of substance use disorder and mental illness together
    • Same team
    • Same location
    • Same time (MI and SA together)

State Initiatives on Dual Disorders

ten treatment principles of iddt
Ten Treatment Principlesof IDDT

1. Integration of substance

abuse & mental health

treatments

  • Same providers within program or agency
  • Team based services
  • Excellent communication
  • Source: Mercer-McFadden, C., Drake, R.E., Clark, R.E., Verven, N., Noordsy, D.L., Fox, T.S. (1998). Substance Abuse Treatment for people with Severe Mental Disorders: a program manager’s guide. New Hampshire-Dartmouth Psychiatric Research Center.

State Initiatives on Dual Disorders

ten treatment principles of iddt7
Ten Treatment Principlesof IDDT

2. Flexibility & specialization

of clinicians

  • Specialties: substance abuse, employment, housing/residential, medical
  • Cross-trained staff

3. Assertive outreach

  • Community based
  • Engage and monitor

State Initiatives on Dual Disorders

ten treatment principles of iddt8
Ten Treatment Principlesof IDDT

4. Recognition of client

preferences

  • Client-centered goals
  • Cultural competence

5. Close Monitoring

  • Medication & response to treatment

State Initiatives on Dual Disorders

ten treatment principles of iddt9
Ten Treatment Principlesof IDDT

6. Comprehensive Services

  • Intensive Case Management (ICM or ACT teams)
  • Supported Employment
  • Family Psychoeducation
  • Illness Management & Recovery
  • Residential

7. Range of Stable Living Situations

  • Wet, damp, and dry & supported
  • Necessary for recovery
  • Housing First

State Initiatives on Dual Disorders

ten treatment principles of iddt10
Ten Treatment Principlesof IDDT

8. The Long-term Perspective

  • No arbitrary time limits

9. Stage-wise Treatment

  • Assessed and staged regularly
  • Interventions focused on stage of readiness for change
  • Engagement, Persuasion, Active, Relapse Prevention

10. Optimism

  • Provider characteristic for selection
  • Celebrate successes

State Initiatives on Dual Disorders

the cost of not integrating treatment
The “Cost” of Not Integrating Treatment
  • Demoralization of treatment professionals - staff attraction, retention, and turnover
  • Decay of treatment systems
  • Lack of public support for treatment
  • Ignoring:
    • Personal goals of people we serve
    • Potential of people we serve
    • Opportunities for their productive participation in community life

State Initiatives on Dual Disorders

slide12

IDDT improves

abstinence outcomes

State Initiatives on Dual Disorders

why focus on employment
Why Focus on Employment?
  • Viewed by many as an essential part of recovery
  • Most consumers want to work
  • A typical role for adults in our society

State Initiatives on Dual Disorders

work is treatment
Work Is Treatment
  • Reduces symptoms of depression.
  • Provides reasons to comply with other treatment goals.
  • Experience fewer hospitalizations.
  • Many feel better about themselves (improved self-esteem).

State Initiatives on Dual Disorders

benefits of competitive employment research evidence
Benefits of Competitive Employment: Research Evidence
  • Increased income
  • Change in self-identity
  • Increased quality of life
  • Reduced symptoms

Sources: Arns, 1993, 1995; Bond, 2001; Fabian, 1989, 1992; Mueser, 1997; Van Dongen, 1996, 1998

State Initiatives on Dual Disorders

competitive employment for people with severe mental illness the gap
Competitive Employment for People with Severe Mental Illness - The Gap
  • Say they want to work: 60%-70%
  • Are currently working: <15%

State Initiatives on Dual Disorders

evidence based principles for se
Evidence-Based Principles for SE
  • Eligibility is based on consumer choice
  • Integrated with mental health
  • Competitive employment is the goal
  • Rapid job search
  • Consumer preferences are important
  • Time-unlimited Follow Along
  • Personalized benefit planning

State Initiatives on Dual Disorders

1 eligibility is based on consumer choice
1. Eligibility Is Based on Consumer Choice

Consumers are not excluded because they are not “ready” or because of:

prior work history, diagnosis, gender, hospitalization history, substance use, symptoms, or other characteristics

State Initiatives on Dual Disorders

integrated with mental health treatment
Integrated with Mental Health Treatment
  • Employment specialists meet frequently with the mental health treatment team

State Initiatives on Dual Disorders

3 competitive employment is the goal
3. Competitive Employment Is the Goal

Competitive jobs:

  • Pay at least minimum wage
  • Are jobs that could be filled by people who do, or do not have disabilities
  • Are hired by the employer

State Initiatives on Dual Disorders

4 rapid job search is used
4. Rapid Job Search Is Used

The service agency avoids:

  • Lengthy pre-employment assessment, counseling, work adjustment or training
  • Volunteer jobs are not promoted as a means to prepare for work

State Initiatives on Dual Disorders

consumer preferences are important
Consumer Preferences are Important
  • Job finding is based on consumers’ preferences, strengths, and work experiences, not on a pool of jobs that are available

State Initiatives on Dual Disorders

follow along supports are time unlimited
Follow-Along Supports Are Time-Unlimited
  • Supported employment staff continue to stay in regular contact with consumer and/or employer without arbitrary time limits

State Initiatives on Dual Disorders

7 personalized benefits planning
7. Personalized Benefits Planning
  • Access to good information about earned income and the effect on benefits increases the likelihood that consumers will return to work

State Initiatives on Dual Disorders

implementation plan for agencies
Implementation Plan for Agencies

Phases:

  • Enabling/Motivating
  • Implementation
  • Sustaining

State Initiatives on Dual Disorders

implementation plan for agencies26
Implementation Plan for Agencies
  • Enabling/Motivation Phase
  • Consensus Building
    • Information sharing
    • Ongoing discussions
  • Steering Committees
  • Baseline Measures

State Initiatives on Dual Disorders

implementation plan for agencies27
Implementation Plan for Agencies
  • Implementation Phase
  • Steering Committee
    • Determines priorities & action plan
  • Kickoffs!
  • Training
    • for the entire treatment team

State Initiatives on Dual Disorders

implementation plan
Implementation Plan
  • Sustaining Phase
  • Implementation Monitoring
    • Ongoing Consultation (team/leader)
    • Fidelity Measure

– Feedback

– Steering Committee

– Service Improvements

  • Learning & Dissemination

State Initiatives on Dual Disorders

champions are vital
Champions are vital

Team leaders and other self-identified champions

--share their enthusiasm

--use the model as a roadmap

--talk to team members about ways

to implement the model

State Initiatives on Dual Disorders

good implementation doesn t happen overnight
Good Implementation Doesn’t Happen Overnight
  • Changing the way we do things is hard!
  • Thinking – Practices - Policies
  • Important to be respectful that people need time to change

State Initiatives on Dual Disorders

project goals
Project Goals
  • Improve the rates of recovery (as indicated by the evidence based practices)
  • Nurture services toward high fidelity
  • Monitor the implementation process and outcomes!
  • Evaluate
  • Learn

State Initiatives on Dual Disorders

nurture toward high fidelity
Nurture toward high fidelity
  • Produce better outcomes
  • Monitors progress toward adherence
  • Results provide direction for “next steps” to improve services
  • Useful tool to help staff and technical assistance consultant/trainer collaborate on strategies

State Initiatives on Dual Disorders

measuring fidelity to the iddt and se models
Measuring Fidelity to the IDDT and SE Models
  • Treatment Fidelity Scales
  • Subscale I. Organizational Characteristics
    • 12 components
  • Subscale II. Treatment Characteristics
    • 14 components – IDDT
    • 15 components – SE

State Initiatives on Dual Disorders

part i organizational characteristics
Part I: Organizational Characteristics
  • Items
  • 01: Program Philosophy
  • 02: Eligibility/Client Identification
  • 03: Penetration
  • 04: Assessment
  • 05: Treatment Plan
  • 06: Treatment

State Initiatives on Dual Disorders

part i organizational characteristics35
Part I: Organizational Characteristics
  • Items
  • 07: Training
  • 08: Supervision
  • 09: Process Monitoring
  • 010: Outcome Monitoring
  • 011: Quality Improvement
  • 012: Client Choice

State Initiatives on Dual Disorders

measuring fidelity to the model
Measuring Fidelity to the Model
  • Independent raters visit a program
    • Interview direct service providers, administrators, consumers, and family members
    • Review charts and other documents
  • Rate each component on a 1-5 scale
  • CCOE provides a qualitative and quantitative report with recommendations

State Initiatives on Dual Disorders

measuring fidelity to the model37
Measuring Fidelity to the Model
  • Scoring ranges
  • 1 = no evidence of implementation
  • 2 = serious departure from full implementation
  • 3 = moderate departure from full implementation
  • 4 = moderate implementation
  • 5 = full implementation

State Initiatives on Dual Disorders

monitoring the implementation process
Monitoring the implementation process
  • Many factors influence the course
  • Each agency and community brings a unique set of characteristics
  • Observing the process helps understand important factors
  • Analyzing observations for useful strategies
  • Measure against outcomes

State Initiatives on Dual Disorders

add to the knowledge base
Add to the knowledge base
  • What does it take to prepare for, develop, and sustain a high quality practices?
  • What are the major facilitators and challenges involved in implementation?
  • Lessons learned will inform others
  • Revised training and consulting tools will be developed from project data

BW

State Initiatives on Dual Disorders

in summary
In Summary
  • People with serious mental illness can recover and work
  • People are much more likely to recover if they have access to IDDT
  • People are much more likely to work if they have access to Supported Employment
  • Implementation requires thoughtful planning and sustained efforts

State Initiatives on Dual Disorders