Concurrent Disorders: A Community Response

1. Concurrent Disorders: A Community Response Allison Potts, MSW, RSW Concurrent Disorders System Integration Consultant Pinewood Centre of Lakeridge Health apotts@lakeridgehealth.on.ca

2. Brief intro � where from � sectors? Positions? Cue cards � your take home message � the quick win you know you could make happenBrief intro � where from � sectors? Positions? Cue cards � your take home message � the quick win you know you could make happen

3. A plan for today: Check in for shared starting point The Who & The What of change Provide overview of current research, its key findings and limitations Review Best practices for CD and Models for understanding CD Discuss CD Capability and how to enhance it within agencies and across the system Profile the CD Network of Durham Region Explore opportunities for CD System building � �take home messages�

4. Who is included? Community? Service providers and service consumers The broad community � all citizens System? Addictions & Mental Health (youth & adult) Hospitals Police Health and Social Services Departments School Boards Shelter/Housing Support System Mutual Aid organizations Community Health Centres And on

5. Any Face Can Be The Face of Concurrent Disorders If you are doing this work, you may have already heard about �those people� � the �difficult to serve�, the �noncompliant�, the �treatment resistant� and you know these are people falling through the cracks. Individuals who someone else was hopefully treating and yet wasn�t. I could have shown you numerous examples, and perhaps my selection tells you something about me - can you tell me who this is?If you are doing this work, you may have already heard about �those people� � the �difficult to serve�, the �noncompliant�, the �treatment resistant� and you know these are people falling through the cracks. Individuals who someone else was hopefully treating and yet wasn�t. I could have shown you numerous examples, and perhaps my selection tells you something about me - can you tell me who this is?

6. Kurt Cobain

7. What happens� when the �system� does not provide good service to individuals with co-occurring mental health and substance use problems? when the system does provide good service to this population?

8. What Are Concurrent Disorders and why is this issue so important? Concurrent Disorders (CD) refers to cases where individuals have any combination of mental health and substance use disorders The number of people affected by mental health and substance use problems is substantial and individuals with CD have reported that treatment is disjointed and unwelcoming Concurrent Disorders are associated with high rates of attrition, missed appointments, costly treatment, poor medication compliance, relapse and readmissions

9. Current Research on CD Prevalence, What Do We Do?, What is Best to Do?

10. Prevalence in the Population you work with? Varies by setting Varies by psychiatric diagnosis Varies by exclusion criteria The prevalence has often been underestimated and frequently was not explored or screened for at all

11. Prevalence of Concurrent Disorders Research suggests that twenty-five to sixty percent of people who have mental health problems will also have a substance use problem during their lifetime. These percentages are similar for people who seek help for their substance use.

12. How many?? Among people who have had an anxiety disorder in their lifetime, 24% will have a substance use disorder in their lifetime. Among people who have had major depression in their lifetime, 27% will have a substance use disorder in their lifetime. Among people who have had schizophrenia in their lifetime, 47% will have a substance use disorder in their lifetime. Among people who have had bipolar disorder in their lifetime, 56% will have a substance use disorder in their lifetime Skinner, O'Grady, Bartha & Parker, 2004

13. Historically, Individuals With CD Have Encountered a Treatment System that is Disjointed and Unwelcoming Sequential Treatment: Patients frequently experienced a �ping pong� effect of moving between components of the system that are unconnected and uncoordinated Parallel Treatment: Simultaneous treatment occurring without consultation or collaboration resulting in high potential for conflicting treatment plans, over-servicing while under-providing Closed doors due to Stigma associated with substance use issues and mental illness and misperception regarding inter-relatedness of CD

14. Access To Treatment Research comparing treatment of patients with a depressive disorder and coexisting substance use issue found that they experience greater complexity of psychosocial needs and clinical presentation than those diagnosed with depression alone and they have fewer admissions and shorter lengths of stay. Brems et al 2006, Journal Of Dual Diagnosis (Research conducted in Alaska Psychiatric Institute). Barriers to research have effected the development of treatment improvements the difficulty for research to be done on complex samples�CD

15. Evidenced Based Practices for CD The most consistent finding across recent studies is that integrated treatment programs are highly effective Ideally, integrated treatment means that the clinician weaves the treatment interventions into one coherent package Several outpatient and residential studies also support the use of Stage-Wise treatments (based on the Transtheoretical Model of Change � Prochaska & DiClemente 1984), Engagement Techniques and Motivational Counselling Techniques Drake, R., Mueser, K., Brunette, M., & McHugo, G. 2004 Drake, Mueser, Brunette and McHugo (2004 � Psychiatric Rehabilitation Journal) reviewed 26 controlled studies published from 1994 � 2003 and made the following conclusions. Integration, in its truest sense, means that clients are not the ones with the sole responsibility of negotiating through the myriad of treatment options, attempting to get a holistic approach, but that a primary clinician takes on this responsibility and has support from the system. Check in with audience re: level of familiarity with stages of change and MI.Drake, Mueser, Brunette and McHugo (2004 � Psychiatric Rehabilitation Journal) reviewed 26 controlled studies published from 1994 � 2003 and made the following conclusions. Integration, in its truest sense, means that clients are not the ones with the sole responsibility of negotiating through the myriad of treatment options, attempting to get a holistic approach, but that a primary clinician takes on this responsibility and has support from the system. Check in with audience re: level of familiarity with stages of change and MI.

16. Considering a Model for Change Many of us have felt like our hands were tied � and have sat with the status quo � but growth is possible even from where we currently sit.Many of us have felt like our hands were tied � and have sat with the status quo � but growth is possible even from where we currently sit.

17.  Concurrent Disorders are an Expectation, not an Exception. This expectation must be incorporated in a welcoming manner into all clinical contact, to promote access to care and accurate identification of the population Dr. K. Minkoff

18. Rationale for System Design (and change) CD as an expectation in all settings, not an exception Rule it out rather than Rule it in Striving for a minimum standard of concurrent disorder capability as a mechanism for reducing the poor outcomes and high costs of concurrent disorders Includes the understanding that each program within the system has a different �job�, but better utilizing these programs and matching services to determine most appropriate interventions

19. System Integration? System integration means the development of enduring linkages between service providers or treatment units within a system, or across multiple systems, to facilitate the provision of service to individuals at the local level. Mental health treatment and substance abuse treatment are, therefore, brought together by two or more clinicians/ support workers working for different treatment units or service providers. Various coordination and collaborative arrangements are used to develop and implement an integrated treatment plan. Health Canada 2002 3min Integration is a �charged� word and it means different things at different levels: Dr. Patrick Smith - At the clinical level: we are recognizing that client needs may co-exist � issues are already integrated in the client At the clinician/health care provider level � there is a recognition that with better knowledge and more skills there can be growth in capacity ---------We are always students!! At the program and service level � an acknowledgement of historical boundaries (many of which were founded by funding) � and the mismatch between this structuring and what clients need At the system level � an ability to draw on each other and share expertise to collaborate in creative ways Moving forward together3min Integration is a �charged� word and it means different things at different levels: Dr. Patrick Smith - At the clinical level: we are recognizing that client needs may co-exist � issues are already integrated in the client At the clinician/health care provider level � there is a recognition that with better knowledge and more skills there can be growth in capacity ---------We are always students!! At the program and service level � an acknowledgement of historical boundaries (many of which were founded by funding) � and the mismatch between this structuring and what clients need At the system level � an ability to draw on each other and share expertise to collaborate in creative ways Moving forward together

20. The Four Quadrant Model is a viable mechanism for categorizing severity of concurrent disorders for purpose of service planning and system responsibility. Dr. K. Minkoff

21. A Four Quadrant Model of Concurrent Disorders

22. Four Basic Characteristics of the CCISC Model (Comprehensive, Continuous, Integrated System of Care) System Level Change Efficient Use of Existing Resources Best Practices � with a recognition that this is not a homogenous group Integrated Treatment Philosophy

23. Eight Principles of Treatment for the CCISC CD is an expectation not an exception The use of the Quadrant model can help guide service planning and tx matching The importance of empathy, hope, integration and continuity Flexibility in treatment approach with variety of modalities Both MI and SA should be considered primary when they coexist A model which embraces the phases and stages of recovery is an appropriate framework for treating CD There is no single correct intervention for CD � quadrant, diagnoses, level of functioning, phase/stage of recovery or change, external factors all must be taken into account � system components develop CD capability across the board and then cohort specific enhancements Individualized treatment goals Adapted from Minkoff & Cline 2004

24. Keys to Implementation of the CCISC Model Top-down/Bottom-up Development Aligning the Parts of the System Inclusion, not Exclusion (programs and populations) Strategic Use of Leverage (Incentives, Contracts, Standards, Licensure, etc�.) Outcomes and CQI (CO-FIT 100?) Model Programs Evaluation of Core Competencies (COMPASS? and CODECAT?) �Action Planning� Train-the-Trainers Minkoff & Cline, 2003 Presentation

25. Assessing and Enhancing CD Capability A strength of this model is the ongoing assessment of CD Capability/Capacity Use of system, organization and clinician assessment tools provides for identification of strengths and weaknesses, action planning and ongoing reassessment

26. Some Options for Assessing CD Capability Internal Needs Assessments � (example in CAMH CD text, or agency developed tool) Minkoff Tools � CO-FIT, COMPASS and Code-CAT DDCAT � Addiction Treatment focused Formal Certification (the U.S. model) � IC&RC/AODA (www.icrcaoda.org) All of the Above

27. Co-FitTM, COMPASSTM and CODE-CATTM A tool-kit developed (and licensed) by Minkoff and Cline that provides assessment of multiple levels of the system All items are rated on Likert scales and are organized into various categories related to each level of service and appropriate focus areas

28. CO-FIT100TM A Systems Measurement tool Divided into two main sections: Implementation and Outcome Very specific, measurable objectives that can be reviewed at regular intervals Expect low scores in the beginning (room to grow!) Action Planning & Quick Wins

29. So, how did all this come together in Durham?

31. The Durham Region Experience - Context CD had very limited exposure/buy-in at the agency level Child/youth and adult systems had many different focuses/mindsets about addictions An review of youth in the system showed 80% of youth have indicators of substance use problems � of these, 20% actually received treatment/counselling

32. The Durham Region Experience - Context Poor linkages existed between child/youth and adult services as well as between mental health and addictions services November 2004 - New funding was announced for �community priorities�

33. The Durham Region Experience - Response How we began Achieved funding for cross sector and cross system �think-tanks� WMHC and Lakeridge partnered to bring the groups together (mainly senior staff) to examine the commonalities and differences in each system Can it be done without this start up money? I think so � that is one of the reasons we are trying to be so open with our information. All of us lose if services do not improve because this is a societal issue.Can it be done without this start up money? I think so � that is one of the reasons we are trying to be so open with our information. All of us lose if services do not improve because this is a societal issue.

34. The Durham Region Experience - Response �Think tanks� held with over 40 agencies represented May 2005 - First focused on identifying the issue and getting �buy-in� to the need to develop a coordinated response to the problem Second session narrowed to reflect commonalities in the various represented systems and set direction for next steps Achieved agreement through all parties that a �Network� approach would facilitate further development

35. The Durham Region Experience � First Steps for the Network Establish a shared understanding of the issues and the role of the network in regard to those issues Develop a workplan that reflects a series of �quick wins� and longer term focuses to establish Completed an on-line �needs assessment� that lead to establishment of training subgroup and a series of educational sessions aimed at enhancing the capacity of front-line staff

36. Concurrent Disorders Network of Durham Region Key Goals: Support Coordinated system and policy development within Durham Region; across agencies, sectors, and ministries and actively share information regarding this client population Provide or support the provision of a forum for this client population Enhance community/system capacity by coordinating educational opportunities Support/enhance system development Provide advice/recommendations with regard to provincial policy development To facilitate Welcoming Strategies that will improve quality of care 3min Winds of change � a very exciting time � change that is evolving across the province, country and internationally A wonderful example of the growth in our field and particularly in our region is the CD Network of Durham Region. This forms the body of our workplan � each aspect of these goals is teased out into measurable, dated outcomes.3min Winds of change � a very exciting time � change that is evolving across the province, country and internationally A wonderful example of the growth in our field and particularly in our region is the CD Network of Durham Region. This forms the body of our workplan � each aspect of these goals is teased out into measurable, dated outcomes.

37. How Dr. Minkoff fits into the Durham Plan Dr. Minkoff came in May 2006 and spent a day with the CD Network in addition to delivering his full day presentation to the community There was significant system buy in to the concepts presented and a consensus to develop a Charter document as recommended by Dr. Minkoff � this was a process!

38. A System Review � The CO-FIT The CD Network did this exercise �item by item� Egos had to be left at the door! Low scores are to be expected � and used to learn how to improve This is a GROWTH PROCESS and will take time

39. Our �Quick Win� from the CO-FITTM Action Planning Consumer Satisfaction? � Have we even been asking? What is it like to enter our system? Is there leverage in feedback to make improvements to the system? RESULT: The Consumer Focus Group Study on Welcoming Lunch Likely hereLunch Likely here

40. Definition of Welcoming A demonstration of empathy and inclusiveness in all clinical encounters where service providers, at every entry point, are attentive and responsive to client needs and facilitate prompt and appropriate service. 1min Welcoming was determined to be an important starting point for the CD Network for several reasons: Client self-report, data in the field on stigma, and a lack of standardized policies that are inclusive of CD were some factors. As well, and not unimportantly, this is a �quick win� and acknowledging what we do in this area can impact the experience of clients but also alter our experience of our work. 1min Welcoming was determined to be an important starting point for the CD Network for several reasons: Client self-report, data in the field on stigma, and a lack of standardized policies that are inclusive of CD were some factors. As well, and not unimportantly, this is a �quick win� and acknowledging what we do in this area can impact the experience of clients but also alter our experience of our work.

41. Elements of Welcoming Reception Tone of voice Right to service Openness Hopeful attitude toward recovery Consistent Approach Acknowledgement of Family members and S.O. Empathic Explanation of process Physical Environment � reading material, information 3min Brief exercise? � maybe ask them to identify elements � what are we best at � where are areas of growth3min Brief exercise? � maybe ask them to identify elements � what are we best at � where are areas of growth

42. The Durham Welcoming Focus Group Research Focus group interviewing was selected for this qualitative research as it can be well suited to obtaining several perspectives about a single topic The research proposal passed the Research Ethics Board of Lakeridge Health in September 2007 Some established groupings of individuals as well as inviting participation from individuals outside of established groups Participants (who have accessed the system in the last 6 mos) will be asked their overall impression of receptiveness from the system, a brief questionnaire using a Likert scale is also administered at the beginning of each session Three groups have been conducted to date, an N=90 is required for completion Sessions are being audiotaped and later transcribed and group notes are also taken The CD Network completed the collective exercise of the CCISC Outcome Fidelity and Implementation Tool (CO-FIT100 TM) which is a systems measurement tool for the CCISC approach (Minkoff & Cline, 2002). Based on this exercise and the resulting discussions, Welcoming Attitudes were highlighted by the CD Network as a priority focus area. Research based on the 2002 Canadian Community Health Survey indicates that the levels of satisfaction with care received are lower among individuals with any diagnosis and the lowest reported satisfaction with care is reported by those with co-occurring mental health and substance use disorders. (Urbanoski, KA, Rush BR, Wild TC, Bassani D, Castel S. In press) Consumer/client experiences of welcoming attitudes at varied access points were considered by the CD Network to be an unexplored area of research in the Region. Six months has been selected as the timeline to increase accuracy of recall and to increase the likelihood that the experiences reflect current experiences of the system. A recognized limitation of this method of research is the lack of representative sampling. Participants will be involved in some type of service so it naturally excludes those who, perhaps due their experiences with services, have opted out of the system; as well as limits inherent in focus groups due to the collaborative nature of responses. A benefit to participants in this research is a potential personal satisfaction at having contributed to the improvement of the system and an opportunity to raise concerns about their experiences and the acknowledgement of being �heard�. Participants will also be surveyed during the focus groups regarding their interest in sitting on the CD Network as a consumer representative The CD Network completed the collective exercise of the CCISC Outcome Fidelity and Implementation Tool (CO-FIT100 TM) which is a systems measurement tool for the CCISC approach (Minkoff & Cline, 2002). Based on this exercise and the resulting discussions, Welcoming Attitudes were highlighted by the CD Network as a priority focus area. Research based on the 2002 Canadian Community Health Survey indicates that the levels of satisfaction with care received are lower among individuals with any diagnosis and the lowest reported satisfaction with care is reported by those with co-occurring mental health and substance use disorders. (Urbanoski, KA, Rush BR, Wild TC, Bassani D, Castel S. In press) Consumer/client experiences of welcoming attitudes at varied access points were considered by the CD Network to be an unexplored area of research in the Region. Six months has been selected as the timeline to increase accuracy of recall and to increase the likelihood that the experiences reflect current experiences of the system. A recognized limitation of this method of research is the lack of representative sampling. Participants will be involved in some type of service so it naturally excludes those who, perhaps due their experiences with services, have opted out of the system; as well as limits inherent in focus groups due to the collaborative nature of responses. A benefit to participants in this research is a potential personal satisfaction at having contributed to the improvement of the system and an opportunity to raise concerns about their experiences and the acknowledgement of being �heard�. Participants will also be surveyed during the focus groups regarding their interest in sitting on the CD Network as a consumer representative

43. The Why�s & How�s of the Charter The need for �top down� commitment to compliment the more �grass roots� approach initially taken by the network Shared understanding of the CCISC Model We began writing with Dr. Minkoff in May 2006 and had a completed document, ready to launch on April 2, 2007

44. Consensus Document and Charter Asserts that the signing partners are agreeing to support and promote the implementation of a CCISC (Comprehensive, Continuous, Integrated System of Care) approach in the Durham Region Planning directed at achieving a minimum of concurrent disorder capable services, incorporating evidenced-based practices across all components of the broader system Signed by: WMHC, Lakeridge Health, CMHA Durham, Social Services Department Region of Durham, Rouge Valley Health Centre, The Youth Centre, CHIMO Youth and Family Services, Fernie House, Community Care Durham � COPE program, Durham Mental Health Services, Durham Regional Police Services 2min April 2 � launch � Better Together� Capacity Building Collaboration Increased awareness of more effective service utilization � client matching (quad model)2min April 2 � launch � Better Together� Capacity Building Collaboration Increased awareness of more effective service utilization � client matching (quad model)

45. The Charter in Practical Terms The Charter is based on Dr. K. Minkoff�s model Welcoming Evidence Based Acknowledgement and Utilization of the Quadrant model Policy Based Consensus Based Change directed to four areas: system, program, clinical practice, clinician 2min It is also grounded by the CDON Policy Framework and Best Practices � and allows us to approach our work in a pro-active manner. Top down and bottom up2min It is also grounded by the CDON Policy Framework and Best Practices � and allows us to approach our work in a pro-active manner. Top down and bottom up

46. Key Focus: Maintaining Emphasis on System Integration and Growth Process Adherence to System-wide Charter and commitment to a Continuous, Comprehensive, Integrated System of Care (Minkoff) System-wide screening for concurrent disorders enable appropriate treatment matching Utilizing the Quadrant Model of Concurrent Disorders to determine system response and requirements, making appropriate use of available resources A focus on Stigma and Welcoming across the system Ongoing system wide capacity building through on-site �Concurrent Disorder Champions� providing Cross-Training, and utilizing system and organizational assessment tools to develop focused action plans to increase CD capacity a a

47. What is CD Capacity Building? Enhancing and Developing Skills, Influencing Change in Organizational Structures, and a Commitment to Overall Health Improvement Hawe et. al. 2000 Addressing the Gap between mental health and addictions treatment Building on the strengths of current services and programs Broadening the Base of treatment and increasing existing capacity

48. Components of CD Capacity Building System based � structures, procedures, policies and practices (important to have top level �buy in�) Resource level � redirection of $ Clinician & Team based � support, information, resources and commitment Partnerships & Collaboration Development of Leadership Champions in the system who will foster leadership and support the change and growth.Champions in the system who will foster leadership and support the change and growth.

49. What can be gained from increased CD Capacity? Reduced Stigma Improved treatment outcomes Improved Screening & Identification Better clinical coordination Enhanced professional development for staff Increased job satisfaction Reduced Stigma within the system and in the society at large and enhanced likelihood and opportunities for advocacy with a more �collective voice�Reduced Stigma within the system and in the society at large and enhanced likelihood and opportunities for advocacy with a more �collective voice�

50. The Important Link to the CD Network Ongoing Feedback Loops Team members will feel heard Transfer of knowledge and potential for system influence

51. Developing a Team Advertising Membership expectations Benefits of membership Establishing meeting times Shared ownership Limiting strains on time

52. Regional Capacity Building Team Logistics Front line workers from mental health and addictions services Representing youth and adult services Monthly meetings � rotating bimonthly between CD related topics and clinical case reviews A new openness with information, resources, transferrable education sessions � a network of �lunch and learn� sessions being encouraged Supported by a Terms of Reference

53. From a member on the CD Capacity Building Team: �As a professional in the addictions field, I need to tap into the needs and challenges facing other professionals in a multitude of different disciplines, in the mental health field.� Participation in the CD Capacity Building team allows me direct access to a diversity of� talents".

54. Functions of the Team: Share clinically relevant information regarding service provision to clients with CD Enhance and support capacity development within the member agencies by a continuous feedback loop of clinical and systemic information relevant to this population Communicate relevant clinical issues that relate to system innovations, opportunities, training needs and barriers to the CD Network of Durham Region Disseminate educational resources and tools to contribute to capacity building across agencies, and sectors in Durham Region

55. Enhancing Capacity with Individual Agency Consultations Tailored support to agencies that have signed the Charter Utilizing Screening tools Training on �street drugs 101� Case reviews Utilization of COMPASSTM tool Education Front-Line Buy-in (don�t underestimate the importance of this) CE LHIN-wide conference in April 2008

56. Consumer Involvement and Feedback Active Advocacy on the CD Network Difference between �representative� and advocate Focus Group Research

57. Ongoing and Next Steps Living the process � being aware of small steps of change Bridging the knowing � doing gap Acknowledging and implementing welcoming practices CD Capacity Building Team continuing to grow Development of Training Modules � Shared Core Competencies and beyond � with focus on Charter organizations Increased consumer feedback and representation on CD Network Ongoing support of use of screening tools in agencies the region Ampersand if timeAmpersand if time

58. What can hold growth back? Working in Silos Client �ownership� Stigma Perceptions, lack of information, need for co-training Fear (for jobs, for funding, of personal and agency limitations)

59. What is your next step? Do you already have a network? Are there individuals funded to do CD work that could focus on system more? Quick wins for your community? What question were you hoping would be answered here?

60. References Boyle, P. and Kroon, H. Integrated Dual Disorder Treatment International Journal of Mental Health, 35, 2, Summer 2006: 70-88. Brems, C. et al. Comparing Depressed Psychiatric Inpatients with and Without Coexisting Substance Use Disorders Journal of Dual Diagnosis, 2 (4), 2006, 71-78. Drake, R., Meuser, K., Brunette M.,McHugo, G. A Review of Treatments for People with Severe Mental Illnesses and Co-Occurring Substance Use Disorders Psychiatric Rehabilitation Journal, 27-4, Spring 2004, 360-374. Minkoff, K and Cline, C. 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 (4):727-43, 2004. Tsanos, A. and Herie, M. A Concurrent Disorders Capacity Bulding Initiative in a Clinical Program for People with Schizophrenia, in Skinner, W. Treating Concurrent Disorders: A Guide for Counsellors Ch. 16. CAMH 2005

61. Resources Hear Me Understand Me Support Me: What young women want you to know about depression � Validity Team � CAMH 2006 Beyond the Label: An Educational Kit to Promote Awareness and Understanding of the Impact of Stigma on People Living with Concurrent Mental Health and Substance Use Problems � CAMH, 2005 Best Practices: Concurrent Mental Health and Substance Use Disorders � Health Canada 2001 The Human Face of Mental Health and Mental Illness in Canada � Government of Canada 2006

62. Websites of Interest www.pinewoodcentre.org CAMH (Centre for Addiction and Mental Health): www.camh.net (particularly tutorials, free PDF resources, etc) www.kenminkoff.com www.cmha.ca http://coce.samhsa.gov/cod_resources/PDF/DDCATIntroVersion23.pdf (powerpoint presentation on DDCAT)