Transcript Lessons Learned: Implementing IDDT

INTEGRATED RECOVERY
Lessons Learned:
Implementing IDDT
Organizational / System Aspect
2 County Examples
Debbie Innes-Gomberg, Ph.D. -Los Angeles
Adrian Carroll, MFT - Stanislaus
January 19, 2007
Organization-Wide and IDDT Team Specific
• IDDT provides principles and tools that
can be used organization-wide to improve
Co-occurring capability throughout
Organization-Wide and IDDT Team Specific
• IDDT provides principles and tools that
can be used organization-wide to improve
Co-occurring capability throughout
• As well as build specific enhanced IDDT
teams
Organization-Wide Elements:
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Commitment
Philosophy
Training
Access policy
Time unlimited
Outcome monitoring
Self-help
Housing and employment
Residential services
Levels of care
Steering committee
System Elements that Support IDDT
Specific Programs:
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Client to staff ratio
Supervising to the model
Team approach
Enhanced trainings
Quality management
Fidelity monitoring
Specific Outcomes
Quality Improvement (forms, processes)
Access to housing (wet, damp, dry)
Use of IDDT in Larger System
Change Efforts in L.A.
• Los Angeles County’s Adult Systems of Care
Transformation
• Creating a continuum of recovery-oriented
services
• Using stages of change to guide service delivery
and treatment planning
• Creating strategies for client flow through the
continuum of services
COUNTY OF LOS ANGELES – DEPARTMENT OF MENATL HEALTH
ADULT SYSTEMS OF CARE TRANSFORMATION-RECOVERY-BASED LEVELS OF OUTPATIENT CARE
Welcoming/Triage
Key Focus: short term, intensive
welcoming and assessment resulting in
quality referrals and enhanced use of
community resources
Strategic Services and Supports
Key Focus: Strategic mental health
and supportive services resulting in
client movement to wellness services
and enhanced recovery.
Wellness Centers
Key Focus: Self-directed services with
peer and professional support geared
toward physical/emotional recovery
and increased community assimilation
IDDT Elements: Integrated assessment
and Tx planning, stage-wise
interventions, use of motivational
interviewing, self-help services, multidisciplinary treatment team
IDDT Elements: Integrated assessment
and Tx planning, stage-wise
interventions, use of motivational
interviewing, self-help services, family
education and support, secondary
interventions for non-responders,
multi-disciplinary treatment team
IDDT Elements: stage-wise
interventions, self-help, family
education and support, focus on health
and well-being
MORS levels: 2-7
MORS levels: 3-6
MORS levels: 6-8
Engagement of clients for < 60 days to
determine level of need, using extended
assessment and recovery scale referral
and linkage to specific service
Evidence based/best practices designed to
enhance recovery, engagement, selfcoordination and coping skills – short
term, intensive and longer term.
Including CBT, DBT, illness
management, referral to housing and
employment specialists within Center
Group and individual treatment
modalities
Peer-directed support groups and
individualized problem solving, including
Wellness Recovery Action Planning
Integrated dual diagnosis interventions
geared toward clients in the
contemplation, preparation and action
phases.
Medication furnished by Nurse
Practitioners
Medication services
Linkage to primary care services, where
possible
More professional problem-solving
assistance than in Wellness Centers
Referrals to housing, employment and
opportunities for community assimilation
Frequent team review of clients to ensure
optimal forward movement
Self-directed crisis management
Peer- led Welcoming/
Greeting/Information Dissemination,
including use of storytelling to enhance
client engagement in services
Introduction to Peer-Run Services
(welcoming and orientation groups for
clients who are unengaged and for those
who are engaged but poorly selfcoordinating)
Use of Service Area Navigator to develop
community supportive services and
enhanced linkage capacity
Crisis Intervention
Medication services
Benefits establishment
Referrals to housing, employment and
opportunities for community assimilation
Healthy living activities, including
psychoeducation and health management
groups
Community integration
Referrals to housing, employment and
opportunities for community assimilation
Full Service Partnerships
Key Focus: Intensive, whatever it takes
service approach for clients who are
homeless, incarcerated, in institutions
or for whom care is provided solely
through the family
IDDT Elements: Integrated assessment
and Tx planning, stage-wise
interventions, use of motivational
interviewing, self-help services, family
education and support, secondary
interventions for non-responders,
access to comprehensive services, multidisciplinary treatment team
MORS levels: At enrollment: 1-2
At graduation: 7
Multidisciplinary team, including housing
and employment specialists and a peer
advocate.
Client to staff ratio <15:1.
Interventions geared toward stage of
change.
Emphasis on obtaining housing and
employment, with intensive ongoing
support and opportunities for community
assimilation
Use of IDDT Model Elements to
Enhance Service Delivery in L.A.
• Focus on person-centered treatment
planning
• Team-based services
• Stage-based assessment and
interventions based on readiness for
change
COUNTY OF LOS ANGELES – DEPARTMENT OF MENTAL HEALTH
ADULT SYSTEMS OF CARE
Big 7 Organizational Transformation
I.
Domains of Change:
Staff Transformation (enhancing staff belief in recovery, instilling hope in
staff).
Staff-consumer interactions (developing welcoming environments,
developing successful strategies to work with challenging individuals).
Organizational structures and processes (collecting and using quality of
life and recovery-based outcome measures, developing structures to
promote consumer flow through the system, building strong team
structures).
Available services and capacity (developing quality of life support
services, strengthening collaboration with other social service agencies,
developing community belonging and connections).
II.
Values of recovery-oriented change:
Hope
Healing
Authority
Community Engagement
III.
Use of Integrated Dual Diagnosis Treatment principles to create a recoveryoriented service continuum:
Integrated assessment and treatment planning.
Use of stage-specific interventions that match client readiness for change,
including motivational interviewing.
Incorporating self-help services into all levels of care.
Team decision-making.
Use of SAMHSA-supported practices such as Illness Management, Family
Education and Support, psychoeducation, Supported Housing and
Employment
Focus on health and wellness.
SAMHSA 4 Quadrants
• Target population for IDDT are those COD
individuals with Serious Mental Illness
Stanislaus experience
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Recovery focus
Integrated system vs. Integrated treatment
Wellness Recovery Center
Exit strategies as a recovery concept
Identify internal experts and early adopters
Recovery Milestones
Stanislaus experience
• Stages of change model:
-SATS (AOD)
-MH stages based on Milestones (MH)
-Stage-based treatment
-Staff change model
STAGE
1
2
3
4
5
STAGES OF
CHANGE
Pre-Contemplation
Contemplation
Preparation
Action
Maintenance
Consensus building
Motivating
Implementing
Sustaining
STAGES OF
Unaware or
IMPLEMENTATION
uninterested
Steps:
1 Ask important
questions
2 Begin the change
process
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4
5
6
7
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10
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12
Conduct a needs
assessment
Develop awareness
of available options
Identify current
practices and
rationales
Examine your
mission, values,
goals, and vision
Check it out
Engage technical
assistance
Assess the pros and
cons
Develop informed
consent and
consensus
Explore concerns
Define your
rationale
Identify stakeholders
Build consensus
Conduct a baseline
fidelity review
Develop a baseline
fidelity action plan
Develop stage-wise
interventions
Maintain oversight
Find your
“champions”
Acquire and integrate
training
Network with
others
Identify financial
resources
Assemble a steering
committee
Conduct a readiness
assessment
Decide to implement
or not
Engage in clinical
consultation
Provide stage-wise
interventions
Develop and monitor
outcomes
Continue to educate
and train stakeholders
Provide ongoing
training
Engage in ongoing
consultation
Expand services
Recruit a team
leader
Plan to start small
Address barriers
Assemble the multidisciplinary service
team
Begin an
implementation plan
Address unintended
consequences
Monitor fidelity
Monitor outcomes
Transform the
organizational
culture
Stanislaus experience
• System Transformation
-MHSA FSP, 2034, ACT
-Wellness Recovery level of care
-LOCUS LOC system, caseload ratio
-Normalizing use of Primary Care
Physician
• Levels of Care
Stanislaus County Behavioral Health and Recovery Services – Draft 7/2005
Stage of
Recovery.
Clinical Risk.
ACT or ACTlite
Mental
Health
Adult
Community
Supports &
Integrated
Services
(ACSIS)
Locus: 4
Level of
Functioning.
Pre-contemplation
to early active
treatment.
High risk.
High degree of
impairment.
Intensive
Community
Supports and
Services
Pre-contemplation
to Relapse
prevention.
Case
Management /
Care
Coordination
< 10-15:1
24/7
>50% in field
Outreach and
engagement.
Multidisciplinary
teams.
Stage-based.
Follow while in
hospital.
<35-40:1
Multidisciplinary
teams.
Stage-based.
Moderate to high
risk.
LEVELS
OF
CARE
Locus: 3
Moderate to high
degree of
impairment.
Wellness
Recovery
Contemplation to
maintenance.
Locus: 2,1
Low to moderate
risk.
Non-Specialty
Mental Health
Primary Care
Low to moderate
impairment.
Beginning
recovery to
maintenance.
Locus:? 1
Low to moderate
risk.
Low to moderate
impairment.
KEY COMPONENTS (that support Recovery)
Housing,
Meds, MD,
Counseling
PsychoEmployment, RN,
and Therapy
Education
Education,
Physical
and
Health
Wraparound
Services
Supports
Extensive use
MH, IDDT and
of wrapAOD readily
around
Readily
available, as
supports,
available.
needed.
Yes
housing and
<150:1
Culturally
employment
appropriate and
services.
strength based.
Housing 1st
Group
Work 1st.
treatment.
Housing 1st
Work 1st.
Independent
living and
competitive
employment
are goals.
Readily
available.
>40:1, 200:1
Brief episodes of
case
management.
Peer supports
for
independent
living and
competitive
employment.
Readily
available.
Possible
med. Rx
groups.
MH, COD and
AOD readily
available, as
needed.
Culturally
appropriate and
strength based.
Group
treatment.
As adjunct to
peer support,
not instead of.
Possible use of
interns or
referral out.
Self-help for
AOD.
Yes
Yes
Peer
Supports
Family
Peers used in
engagement
and outreach
and as role
models of
hope and
recovery.
Self-help
encouraged.
Family
actively
engaged as
resource,
engagement
approach and
as natural
supports.
Peers used in
engagement
and outreach,
as well as in
building
supports, role
model hope
and recovery.
Self-help
encouraged.
Family
actively
engaged as
resource,
engagement
approach and
as natural
supports.
Self-help
encouraged.
Extensive use
of peer
supports as
primary
component of
this level.
Family selfhelp actively
supported.
Primary Care Physician may provide these services. Medication support, medical services limited counseling,
education and community referrals.
Stanislaus experience
• Client flow through System
-Early expectations
-Ease of re-admission
-SSI concerns
-PCP relationships
-Peer support throughout
-Recovery conversation
-Transparency of treatment process
-Measurement and accountability
Team Structure
SUPPORT WHEEL
Phone Numbers
My Recovery
Be Selective In
Choosing Support
Phone Numbers
Use In A
Circular
Manner So
Not To Burn
Out Any One
Source
Cornerstones of Empowerment
Developed by Consumers and Family Members
7/08/06
I have the right to know my diagnosis, criteria, and what medications are used to treat said diagnosis AND I
have the responsibility to fully participate in my treatment plan. (Welfare & Institutions Code 5325.1)
I have the right to know what my treatment options are AND I have the responsibility to inform and educate
staff about what treatments have worked or not worked for me currently and in the past.
(Welfare & Institutions Code 5325.1)
I have the right to feel comfortable to ask questions, and have the time to understand and be understood.
(Customer services & client empowerment)
I have the right to a name and phone number, map or directions, when referrals are made, and a right to call
back if a connection wasn't made AND I have the responsibility to follow through on referrals and to call back if
a connection wasn't made. (BHRS Coordination of Services for Consumers and Families 70.1.110 )
I have the right to file a complaint and be supported on that AND I have the responsibility to let staff know what
complaints or problems I am experiencing with the staff (program) so they can be resolved. If they cannot be
resolved then I have the responsibility to file a complaint. (Patients rights)
I have the right to define who I want involved as my family and support system with my treatment AND I have
the responsibility to let staff know what family members, friends, support system I want involved with my
treatment. (Cultural Competency Clinical Standards, Client & Family Involvement in Services Policy 90.1.111)
I have the right to a choice and explanation of the providers on my treatment team AND that I be an active
participant in my treatment. (N.T.T.P Curriculum, Client & Family Involvement in Services Policy 90.1.111)
I have the right to ask for a change of provider when I feel my provider and I are not a good partnership AND I
have the responsibility to inform staff about what type of provider I need when I feel my provider and I are not a
good partnership. (Patients Rights)
I have the right to be respected for my beliefs, sexual orientation, ethnicity, culture, religion, spirituality, etc
AND I have the responsibility to be respectful of others beliefs, sexual orientation, ethnicity, culture, religions,
spirituality, etc. (BHRS NON DISCRIMINATION Policy 40.2.108 policy)
I have the right to express, in a considerate way, my feelings and emotions on issues without providers
minimizing my concerns AND I have the responsibility not to blame others for my feelings and emotions.
(Customer service)
I have the right to pursue a safe independent living arrangement that works for me AND I have the
responsibility to choose a place to live and to be responsible in maintaining my home.
(Recovery Story B. Farr, Wellness Recovery Action Plan)
I have the right to know all resources such as support people, self help, warm line, crisis services, officer of the
day to call on when my case manager, clinician, counselor is not available AND I have the responsibility to use
my support system, develop my unique coping skills and to share them with my provider, family members and
others who support me. (Relapse Prevention Plan, Advanced Directives)
I have the right to be fully informed of volunteer opportunities to strengthen my recovery AND I have the
responsibility to share my recovery and to participate in opportunities that strengthen my recovery.
(Milestones in Recovery)
I have a right to review my medical record according to the H.I.P.A.A. regulations.
(BHRS H.I.P.A.A. policy)
Stanislaus experience
• IDDT as model for implementing any EBP
-Levels of implementation
• Fidelity Scales as a guide and measure
• Promotes team approach
-Multidisciplinary
-AOD, Psychiatrist, RN, CM, Clinician, E&H
• Stages
-provides conceptual framework to bridge
MH/AOD, Harm reduction & recovery
-Consumer centered
Summary of Lessons Learned
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QUESTIONS