Building Integrated Coordinated Services for People With Co-Occurring Disorders

1. 1 Building Integrated & Coordinated Services for People With Co-Occurring Disorders Making Waves for Change CMHA National Conference August 2008 Intro slide as people enterIntro slide as people enter

2. 2 Presented by: Nicole Chammartin CMHA Winnipeg & Kelly Southworth Winnipeg Regional Health Authority, Community Mental Health Program Nicole & KellyNicole & Kelly

3. 3 Co-Occurring Mental Health and Substance Use Disorders Initiative (CODI) Manitoba Kelly’s SectionKelly’s Section

4. 4 Terminology: Co-Occurring Disorders Concurrent Disorders Dual Disorders Dual Diagnosis Co-existing Disorders Co-morbid Disorders Any combination of a mental health and a substance use disorder as per DSM IV TR MH Axis I & Axis II diagnoses Substance Use Disorders May also include problem gambling (pathological gambling) Any combination of a mental health and a substance use disorder as per DSM IV TR MH Axis I & Axis II diagnoses Substance Use Disorders May also include problem gambling (pathological gambling)

5. 5 CODI Specialized Services or Systems Change? Kelly’s SectionKelly’s Section

6. 6 Expert Consensus on Need The number of people with co-occurring disorders tends to be highly underestimated. These individuals: Are highest in risk for harm Incur the highest service costs Experience the poorest outcomes K. Minkoff, MD 40% to 60% of those with severe mental illness will develop a substance use disorder at some time in their lives, and at any given point in time, half of those will have a co-occurring disorder. (Health Canada, 2002) 40% to 60% of those with severe mental illness will develop a substance use disorder at some time in their lives, and at any given point in time, half of those will have a co-occurring disorder. (Health Canada, 2002)

7. 7 Increased Risk for Harms When compared with people who have a mental health problem alone, people with dual diagnosis are more likely to have: Increased likelihood of suicide More severe mental health problems Homelessness and unstable housing Increased risk of victimization Increased risk for HIV infection More contact with the criminal justice system Increased risk of being violent Royal College of Psychiatrists, 2002

8. 8 Common Barriers to Service Difficulty in diagnosing co-occurring disorders Most programs are not designed to accommodate clients with CODs Lack of specialized services and cross-trained clinicians Differences between MH and SU treatment philosophy and methods Lack of common assessment language and tools between the MH and SU systems Organizational and funding barriers to service collaboration between what are fundamentally separate (non)service systems

9. 9 Decision: Systems Change CODs are common, diverse, & complex No one “specialized” program could meet all needs for all clients If everyone in the service systems worked “a little bit” differently, great improvements for people could be achieved

10. 10 CODI Project Purposes and Goals Kelly’s SectionKelly’s Section

11. 11 CODI Vision CODI is a strength-based, client directed, and recovery-oriented service model, where the focus is on helping to facilitate positive recovery experiences and outcomes for the client in spite of service and system limitations.

12. 12 Overall Purposes To resolve system level, service coordination issues that frequently result in ineffective care and poor treatment outcomes. To enhance system capacity to deliver effective, coordinated care, and to improve treatment outcomes.

13. 13 Goal of the Project To create a coordinated mental health and addiction service delivery system that is able… To provide universally accessible, welcoming, and integrated services for persons with co-occurring mental health and substance use disorders, and Results in improved system access, seamless service experience, & increased service satisfaction.

14. 14 Service Level Focus Supporting the development of integrated and coordinated care at the level of clinical practice With system level supports But without system level administrative re-organization.

15. 15 Expected Outcomes Universally welcoming, dual diagnoses capable services, anchored in program policy and procedures Improved access to and coordination of services Cross-trained clinicians Enhanced specialized care services Improved system data Improved outcomes for clients Increased satisfaction for clients and families

16. 16 CODI Project History, Partners, and Structure Nicole’s SectionNicole’s Section

17. 17 Sponsoring / Supporting Partners Manitoba Health and Healthy Living, Mental Health and Addictions Branch Manitoba’s 11 Regional Health Authorities Addictions Foundation of Manitoba CODI began as a local project, based in Winnipeg. The initiating partners were the WRHA and AFM, with Manitoba Health invited from the very early stages. It began out of a locally identified need. As AFM is a provincial organization, there was some involvement of people from outside of Winnipeg from the start. Based on the success of the Winnipeg CODI, Manitoba Health mandated the roll-out of the initiative province-wide, requiring all RHAs to participate.CODI began as a local project, based in Winnipeg. The initiating partners were the WRHA and AFM, with Manitoba Health invited from the very early stages. It began out of a locally identified need. As AFM is a provincial organization, there was some involvement of people from outside of Winnipeg from the start. Based on the success of the Winnipeg CODI, Manitoba Health mandated the roll-out of the initiative province-wide, requiring all RHAs to participate.

18. 18 Manitoba’s RHAs are diverse—some large in size but small in population, others small in both area covered and population served (Churchill) but unique, and others metropolitan, providing tertiary services for the entire province.Manitoba’s RHAs are diverse—some large in size but small in population, others small in both area covered and population served (Churchill) but unique, and others metropolitan, providing tertiary services for the entire province.

19. 19 AFMs regional areas do not correspond with RHA boundaries, thereby creating some jurisdictional issues that mirror the wider systems’ issues and barriers.AFMs regional areas do not correspond with RHA boundaries, thereby creating some jurisdictional issues that mirror the wider systems’ issues and barriers.

20. 20 Other Key Supporting Partners include… Anxiety Disorders Association of Manitoba Behavioural Health Foundation Inc. Canadian Mental Health Association Manitoba Schizophrenia Society Mood Disorders Association of Manitoba In addition, there are approximately another 30 organizations that are involved with CODI in the Winnipeg region, representing mental health, substance use, primary care, and justice.In addition, there are approximately another 30 organizations that are involved with CODI in the Winnipeg region, representing mental health, substance use, primary care, and justice.

21. 21 AFM, Manitoba Health, and the RHAs are the sponsoring bodies across the province. The Provincial CODI Leadership Team is made up of representatives from each of the RHAs, AFM, Manitoba Health, and the Mental Health Self-Help Organizations. The composition of each of the 8 regional leadership teams varies, but usually consists of local staff from the RHA and AFM, with other organizations sometimes represented. In addition, many participating agencies have their own, internal CODI leadership teams, to help move CODI along within each organization.AFM, Manitoba Health, and the RHAs are the sponsoring bodies across the province. The Provincial CODI Leadership Team is made up of representatives from each of the RHAs, AFM, Manitoba Health, and the Mental Health Self-Help Organizations. The composition of each of the 8 regional leadership teams varies, but usually consists of local staff from the RHA and AFM, with other organizations sometimes represented. In addition, many participating agencies have their own, internal CODI leadership teams, to help move CODI along within each organization.

22. 22 Project Development History 2001 Interagency Planning – Winnipeg Region 2002 Hiring of consultants & coordinator – Winnipeg Region Selection & training of trainers – Winnipeg Leadership & stakeholders consultations-Winnipeg 2003/4 Manitoba Health initiates rollout of CODI across province Provincial competencies & workshop package developed Provincial ‘deliverables’ set for RHAs & funded agencies 2005-7 Province-wide staff training rollout Provincial CODI Policy developed Provincial MH data sets incorporate CODI elements 2001—WRHA, AFM, and Manitoba Health. Literature review. 2002—external consultants: Drs. Ken Minkoff and Christy Cline provided 1 year of training to trainers and consultation to leadership/stakeholders, visiting Winnipeg approximately every 2 to 3 months. Focus was on promoting system change and identifying sound clinical practices. Trainers were trained to be “change agents” within their individual organizations. 2003/4—Manitoba Health mandates CODI province-wide, implementing required reporting criteria, as well as funding the development of a standardized training package for delivery to front-line service providers. 2005-7—focus shifted to primarily clinical issues, particularly “training” individual front-line service providers. Systems coordination, service agreements, etc. took a backseat.2001—WRHA, AFM, and Manitoba Health. Literature review. 2002—external consultants: Drs. Ken Minkoff and Christy Cline provided 1 year of training to trainers and consultation to leadership/stakeholders, visiting Winnipeg approximately every 2 to 3 months. Focus was on promoting system change and identifying sound clinical practices. Trainers were trained to be “change agents” within their individual organizations. 2003/4—Manitoba Health mandates CODI province-wide, implementing required reporting criteria, as well as funding the development of a standardized training package for delivery to front-line service providers. 2005-7—focus shifted to primarily clinical issues, particularly “training” individual front-line service providers. Systems coordination, service agreements, etc. took a backseat.

23. 23 Project Development History 2006 CODI Outreach Team (WRHA CMHP) Specialized services & consultations 2007 Most participating agencies moving to operationalize & embed CODI practice through development of practice guidelines 2008 CODI partnership with Manitoba Justice 2009 Summer Institute planned with Brandon University 2006—CODI Outreach Team, a specialized community mental health service providing intensive case management for individuals with co-occurring disorders and high needs began, led by Dr. Adrian Hynes. The team also provides DBT to individuals with co-occurring Axis 2 issues (personality disorders) and substance abuse concerns. 2007—With large numbers of staff having completed CODI workshops, agencies moved back to a focus on embedding CODI-consistent practice in policies, guidelines and procedures. 2008—CODI Winnipeg began a partnership with Manitoba Justice where 2 staff from Justice were trained as trainers (expanding the core of trainers), and now Probation staff from Winnipeg are invited to participate along with mental health and addictions staff in CODI Workshops. 2009—Manitoba Health, WRHA, and AFM have partnered with Brandon University’s School of Psychiatric Nursing to sponsor a summer institute. Other RHAs and CODI stakeholders will also be invited to participate. The focus of the institute will be on developing cultures of learning and continuous improvement where new knowledge can be embedded in practice. The goal is to transform from a reliance on “one-shot” training opportunities towards a use of workshops to create awareness, followed up with peer coaching models to develop and sustain practice skills.2006—CODI Outreach Team, a specialized community mental health service providing intensive case management for individuals with co-occurring disorders and high needs began, led by Dr. Adrian Hynes. The team also provides DBT to individuals with co-occurring Axis 2 issues (personality disorders) and substance abuse concerns. 2007—With large numbers of staff having completed CODI workshops, agencies moved back to a focus on embedding CODI-consistent practice in policies, guidelines and procedures. 2008—CODI Winnipeg began a partnership with Manitoba Justice where 2 staff from Justice were trained as trainers (expanding the core of trainers), and now Probation staff from Winnipeg are invited to participate along with mental health and addictions staff in CODI Workshops. 2009—Manitoba Health, WRHA, and AFM have partnered with Brandon University’s School of Psychiatric Nursing to sponsor a summer institute. Other RHAs and CODI stakeholders will also be invited to participate. The focus of the institute will be on developing cultures of learning and continuous improvement where new knowledge can be embedded in practice. The goal is to transform from a reliance on “one-shot” training opportunities towards a use of workshops to create awareness, followed up with peer coaching models to develop and sustain practice skills.

24. 24 Proposed Solution: Core Concepts Kelly’s SectionKelly’s Section

25. Systems Integration: The process by which individual systems organize themselves to implement services integration to clients with COD and their families. Services Integration: Any mechanism by which appropriately matched interventions for MH and SU are combined in the context of a clinical relationship with an individual clinician or clinician team so that the client/family experiences the intervention as a client/family centered, integrated experience. Appropriateness considerations would need to include level of program competency (DDC or DDE)Systems Integration: The process by which individual systems organize themselves to implement services integration to clients with COD and their families. Services Integration: Any mechanism by which appropriately matched interventions for MH and SU are combined in the context of a clinical relationship with an individual clinician or clinician team so that the client/family experiences the intervention as a client/family centered, integrated experience. Appropriateness considerations would need to include level of program competency (DDC or DDE)

26. 26 Welcoming Practice Wherever the client appears in the system of care, it is the right place for them to access the services of the system NO WRONG DOOR

27. 27 Dual Diagnosis Capability (DDC) Programs “address CODs in their policies and procedures, assessment, treatment planning, program content and discharge planning” Staff are “able to address the interaction between mental and substance-related disorders and their effect on the patient’s readiness to change—as well as relapse and recovery environment issues—through individual and group program content.” ASAM 2001

28. 28 Dual Diagnosis Enhanced (DDE) Services “place their primary focus on the integration of services for mental and substance-related disorders in their staffing, services and program content.” ASAM 2001 Provide unified treatment for persons with more severe and disabling CODs

29. 29 DDC Level Service Integration:Key Service Components Welcoming atmosphere Universal Integrated Screening Targeted Integrated Assessment Integrated service/treatment planning as indicated Appropriately adjusted service delivery Service coordination and care management

30. 30 Division of Responsibility By Problem Severity

31. 31 Implementing System Change Strategic Framework Nicole’s SectionNicole’s Section

32. 32 Basic Assumptions Large service organizations and service systems are naturally resistant to change Planned change requires concerted efforts to direct, manage and sustain change Sustainable change must be imbedded at all levels of the system, the organization and service practice

33. 33 System Change Requires: Opinion leaders who endorse the change System administrators and program directors that are knowledgeable and supportive Policies that provide incentive for change Supervisors skilled in supporting new practices Service providers with knowledge, skills and attitudes consistent with new practices Staff and consumer input and feedback The Change Book, ATTC 2000

34. 34 Implementation Levels System Level Change—Consensus, alliance and collaboration around common vision Program Level Change—Policy and procedure alignment, plus service adaptations Practice Level Change—Revised practice standards, guidelines and protocols Competency Level Change—Cross-training and supervisionSystem Level Change—Consensus, alliance and collaboration around common vision Program Level Change—Policy and procedure alignment, plus service adaptations Practice Level Change—Revised practice standards, guidelines and protocols Competency Level Change—Cross-training and supervision

35. 35 Implementing System Change A Model, Resources & Tools Kelly’s SectionKelly’s Section

36. 36 The CCISC ModelKen Minkoff, MD Comprehensive, Continuous, Integrated System of Care

37. 37 CCISC Principles COD should be an expectation Universal welcoming and system access Empathic, hopeful and continuous relationships Balancing challenging and care-giving approaches Concurrent response to both as primary disorders Stage/phase-specific approaches Individualized service plans Individualized outcomes + harm reduction options

38. 38 Expectations of Participating Agencies All funded MH & SU service providers were expected to participate Changes were to be undertaken within the context of existing operational resources Changes were to be based on evidence & consensus-based best practice principles Changes were to reflect an integrated service philosophy, common language and clinical information frameworks

39. 39 Assumptions MH and SU programs do not have to change dramatically in order to serve people with CODs Programs do not need to be fully integrated or fall under unified administrative authority for them to become effective in delivering integrated services Staff trained in either MH or SU treatment do not have to become experts in both specialties, but they do require a basic level of competency in the field which is not their specialty

40. 40 Consensus Agreement Signature indication of formal support CODI Consensus document outlines: Best Practice Principles of CCISC Model Basic Expectations of Change Plan Action Expectations for agencies/programs Initial Action Expectations: Assign & empower process leader Action planning Staff training Develop welcoming policies Competency self-assessment Screening, identification & reporting Interagency coordination & collaboration

41. 41 Provincial CODI Policy 2007 Attain and maintain “co-occurring capability” (DDC) Establish and implement policies and procedures Ensure all clients screened for COD Ensure all clients with positive screen receive a comprehensive integrated assessment Ensure that all clients who are assessed as having a COD have an integrated treatment plan Ensure data is collected and reported annually

42. 42 Supporting the Front Line Training, Networking, Resources, Supervision/Coaching Kelly’s SectionKelly’s Section

43. 43 The Role of Training Systems change involves creating a mechanism by which a desired change is accepted, incorporated and reinforced at all levels of an organization or system. Training provides a mechanism for transferring knowledge about the desired change and the means to achieve it. The Change Book, ATTC 2000

44. 44 Clinical Competencies, Training Guidelines, & Workshops Welcoming, Empathic & Hopeful Stance COD Population Needs & Barriers MH/SU Clinical Knowledge & Best Practices Change & Recovery Models Crisis Response Screening & Assessment Integrated Treatment/Rehab Planning Coordination of Services Facilitation of Recovery

45. 45 CODI Workshops: How they work in Winnipeg Common curriculum Sponsoring agencies fund Co-facilitated by MH & SU Participating agencies provide front-line facilitators Open registration for all participating agencies Mix of MH & SU staff in every workshop Not every staff takes all 10 workshops

46. 46 Winnipeg CODI Network “Community of Practice” for interested clinicians 30+ participating organizations Rotating host agency plans content Case discussions, tour & overview of services, video discussions, resource sharing, consumer presentations . . .

47. 47 CODI Why it’s working Kelly’s SectionKelly’s Section

48. 48 Strength / Success Factors Strong consensus on conceptual and values framework Strong commitment from sponsors, lead agencies & individual clinician-champions Strong, empowered leadership/participatory processes Collaboration technician / project coordinator Informal “Community of Practice” networks Quality training resources & committed trainers Funder ‘deliverables’ and other ‘reward’ incentives Focus of change on enabling collaborative practice Emerging clinical expertise and specialized self-help Broadly accessible clinical consultation—Winnipeg

49. 49 Incremental Agency Engagement Plan-Winnipeg Region-

50. 50 CMHA Winnipeg How CODI works in an individual organization Nicole’s SectionNicole’s Section

51. 51 CMHA Winnipeg and CODI CODI Member since inception in 2001 Offer Recovery and Rehabilitation services in Winnipeg (Approximately 120 clients per year) Historically had avoided working with clients on substance abuse issues (lack of expertise) Now identify approximately 25% of clients as having CODs - Common for an agency to be closer to 60% COD, still building capacity in identifying, disclosure issues are common- Common for an agency to be closer to 60% COD, still building capacity in identifying, disclosure issues are common

52. 52 CODI at CMHA Winnipeg

53. 53 CODI at CMHA Winnipeg

54. 54 CODI at CMHA Winnipeg Create annual agency plan for CODI Have incorporated CODI principles into all client work Training in house of all service R&R staff for all CODI levels *PROMOTE HARM REDUCTION

55. 55 CMHA Winnipeg CODI Tools Use of MIDAS and ILSA for screening and assessment (Minkoff) Creation of specific CODI work path Revamped tools to serve broader population(i.e. compulsive behaviours like gambling, eating & sex) Creation of the Change Tool Box

56. 56 Changes Tool Box Created to assist clients to work through Stages of Change (compilation of tools) Can be used individually or as part of a program Develops personalized action plans for change CD’s available for purchase through CMHA Winnipeg (www.cmhawpg.mb.ca)

57. 57 CMHA Winnipeg Outcomes Current outcome evaluation underway Reports from staff demonstrate increased satisfaction with work Reports from client demonstrate satisfaction with program and results

58. 58 Outcome Data- CMHA Winnipeg

59. 59 Outcome Data- CMHA Winnipeg

60. 60 CODI at CMHA Winnipeg

61. 61 CODI at CMHA Winnipeg

62. 62 Contact Us Nicole Chammartin Executive Director CMHA Winnipeg 432 Ellice Ave. Winnipeg, MB R3B 1Y4 204-982-6103 Nicolec@cmhawpg.mb.ca Kelly Southworth Practice Development Coordinator WRHA Community Mental Health Program 189 Evanson St. Winnipeg, MB R3G 0N9 204-940-1695 Ksouthworth@wrha.mb.ca

63. 63 Recommended Reading COCE Overview Papers The Co-Occurring Center for Excellence (COCE), funded through the Substance Abuse and Mental Health Services Administration (SAMHSA), has a mission to: Receive & transmit advances in treatment Guide enhancements in infrastructure & clinical capacities of service systems Foster infusion & adoption of concensus & evidence-based COD practice http://www.coce.samhsa.gov/