Transcript Co-Occurring Disorders Center for Excellence (COCE)
Stanley Sacks, PHD, CIRP, NDRI, New York, NY Michael Chaple, PHD, CIRP, NDRI, New York, NY ChackuMathai, CPRP, NYAPRS, Albany, NY
presentation to — NYAPRS 29 th Annual Conference, “Bringing Recovery Home for All,” September 14-16, 2011, Hudson Valley Resort and Conference Center, Kerhonkson, NY
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What is CEIC’s purpose?
Fosters the implementation of integrated care in screening, assessment, and evidence-based interventions for New York State (NYS) residents with co-occurring conditions and facilitates OMH and OASAS initiatives in this area
2
May, 2007 December, 2007 June 20 & July 31, 2008
Timeline
New York State (NYS) Office of Alcoholism & Substance Abuse Services (OASAS) and Office of Mental Health (OMH) convene a Co-occurring Disorders (COD) Task Force (2007) The NYS COD Task force makes recommendations The Directors of licensed substance abuse and mental health programs receive two letters with recommendations for integrating services for COD from the Commissioners of OASAS and OMH
November 1, 2008
The New York State Health Foundation (NYSHealth) funds the Center for Excellence in Integrated Care (CEIC, pronounced “seek”) 3
What does CEIC do?
Provides technical assistance
(hands-on, intensive, and longitudinal)
Engages Leadership Performs on-site assessments Presents site reports Conducts provider forums Builds collaborations and informal networks Holds Peer Recovery Workshops Supplies ongoing support, guidance, and consultation
Links programs to resources, such as FIT, TIP 42, and related in service training, as well as other trainings and curricula 4
CEIC Assessment Methods
Uses DDCA[MH]T
(Dual Disorder Capability in Addiction Treatment and Dual Disorder Capability in Mental Health Treatment)
Samples individual clinics within regions
Employs direct onsite observation
Scores and reports on 7 domains and overall
Makes specific recommendations to raise capability
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Improving Co-occurring Capability
Recommendations by DDCA[MH]T Dimensions
I II III IV V VI VII Dimensions of Capability Levels of Capability SA/MH only Capable Enhanced Program Structure Program Milieu Clinical Process: [screening &] Assessment Clinical Process: Treatment Continuity of Care Staffing Training Program mission, structure and financing, format for delivery of co-occurring services Physical, social and cultural environment for persons with mental health and substance use problems Processes for access and entry into services, screening, assessment &diagnosis Processes for treatment including pharmacological and psychosocial evidence-based formats Discharge and continuity for both substance use and mental health services, peer recovery supports Presence, role and integration of staff with mental health and addiction expertise, supervision process Proportion of staff trained and program’s training strategy for co-occurring disorder issues 6
D
ual Disorder Capability
Enhanced
5 4,5 3,5
Capable
3 4 2,5 2
2.70
(N=300) Transformation of the Service System may be said to occur when the majority of outpatient clinics are rated capable or above
3.06
3.09
2.76
2.48
2.50
2.53
2.47
1,5
Basic
1
Total Score
Program Structure Program Milieu Assessment Treatment Continuity of Care Staffing Training
Scores based on DDCA[MH]T = Dual Diagnosis Capability in addiction [Mental Health] Treatment Index 7
DDCA[MH]T Score
Enhanced –
5 4
Capable –
3 2
Basic –
1
Program Structure
2.48
Program Structure
Recommendations
Update agency mission statement (or develop a program service statement) to reflect that co-occurring services are provided
Ensure that the program’s licensure agreement (or state permit) identifies the target population as individuals with substance related disorders (for addiction clinics) or mental health disorders (for mental health clinics) but does not restrict the program from treating individuals with co occurring mental disorders or substance use disorders, respectively
Demonstrate that your program’s system of care meets the definition of collaboration; that is, shared responsibility for treating a person with co-occurring conditions, involving regular and planned communication, and shared progress reports or memoranda of agreement 8
DDCA[MH]T Score
Enhanced –
5 4
Capable –
3
Program Milieu Recommendations
Expect and welcome clients with both disorders
Ensure that materials for both substance related and mental disorders are posted and distributed
Engage in a discussion with staff regarding "attitudes and values" towards treatment of co-occurring disorder 2.50
2
Basic –
1 Program Milieu
9
DDCA[MH]T Score
Enhanced –
5
Clinical Process — Screening
(one item from Assessment Domain)
Recommendations
Implement one of the state-recommended standardized screening instruments (these are all free, brief, and do not require clinical expertise to administer)
4
Establish a protocol that will direct all those with a positive score on the screen to an integrated assessment Capable –
3 2
3.24
Separate the screen from the assessment protocol; the screen should drive the assessment, but it is not a diagnostic evaluation nor should it be used to determine severity of a mental health or substance use condition Basic –
1 Screening (one item from Assessment Domain)
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Clinical Process — Assessment Recommendations DDCA[MH]T Score
Enhanced –
5 4
Provide a comprehensive assessment that covers all 12 recommended domains and includes a thorough substance use and mental health evaluation
Obtain diagnostic evaluation as part of the assessment process
Build on the stages of change for both disorders Capable –
3 2
3.06
Synthesize assessment information into main problem areas that need to be addressed
Use assessment data to inform the treatment plan Basic –
1 Assessment
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Clinical Process — DDCA[MH]T Score Treatment
Integrated COD Services
Recommendations
Allow the free expression and discussion of co-occurring problems in group and individual sessions Enhanced –
5
Ensure inclusion of mental health and substance use content in all groups
4
Capable –
3
2.53
Create a “home” for co-occurring disorders in the treatment schedule (i.e., offer a psycho-educational class for COD and a dual recovery group)
Provide supervision and coaching to increase staff competency in COD
2
Basic –
1 Treatment: Integrated COD Services
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Clinical Process — Treatment
Evidence Based Interventions
Recommendations
Data from OASAS Local Service Plan (LSP) Survey
Organize treatment with a stage-wise approach 100% 80% 60% 40%
Build staff competencies in Motivational Interviewing
Employ existing trauma curriculums; for example, Seeking Safety and Trauma Recovery & Empowerment Model (TREM)
Offer Wellness Self-Management curriculum to integrate co-occurring content further 20%
Gradually introduce other NYS recommended evidence-based interventions 24% 0%
Evidence-based Interventions
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DDCA[MH]T Score
Enhanced –
5 4
Capable –
3 2
2.76
Continuity of Care Recommendations
Ensure that the discharge plans address both the substance use and mental health disorders
Encourage and arrange connections to community support groups during treatment and as part of discharge planning (e.g. Double Trouble in Recovery, Dual Recovery Anonymous)
Provide a supply of medication sufficient to span from discharge until continuing treatment has been established Basic –
1 Continuity of Care
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DDCA[MH]T Score
Enhanced –
5 4
Capable –
3 2
Basic –
1
3.09
Staffing
Staffing Recommendations
Ensure that at least one direct care staff member has mental health and substance use competency or licensure
Provide on–site clinical supervision sessions that include a focus on co occurring disorders
Ensure that team meetings and case reviews incorporate co-occurring disorders 15
DDCA[MH]T Score
Enhanced –
5 4
Capable –
3 2
Basic –
1
2.47
Training
Training Recommendation
Demonstrate that the program has a written training plan
Maintain and enhance staff competencies in co-occurring services using up-to-date literature, films, and other media, as well as in-service and external trainings
Train staff in specialized treatment approaches and pharmacotherapy 16
Training — Focus on Integrated Treatment Recommendation
Urge staff to enroll in FIT (Focus on Integrated Treatment) online learning
Description of FIT
This training helps practitioners gain a firm foundation in evidence-based integrated treatment for COD including screening and assessment, stage wise treatment, motivational interviewing, and more. Additional modules help clinical supervisors develop their supervision skills and guide agency leaders through changes to ensure sustainability of integrated treatment.
Along with learning modules, CPI (the Center for Practice Innovation) offers inline implementations supports through webinars, “Ask the Expert” forums, and discussion threads.
The training is comprised of 35 individual modules developed alongside experts at the Dartmouth Psychiatric Research Center
http://www.practiceinnovations.org/CPIInitiatives/FocusonIntegragedTreatmentFIT/tabid/99/Default.asp
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Training — TIP 42 Recommendation
Refer to and use TIP 42 and its associatedin-service training curriculum
Description of TIP 42
1. Introduction 2. Definitions, Terms, & Classification 3. Systems for COD 4. Keys to Successful Programming 5. Assessment 6. Strategies for Working with Clients with COD 7. Traditional Settings & Models 8. Special Settings & Models 9. Special Settings & Specific Populations 10. A Brief Overview of Specific Mental Disorders & Cross-Cutting Issues 11. Substance-Induced Disorders http://store.samhsa.gov/product/SMA08-3992 18
Improving Co-occurring Capability
Quick Guide
— 10 recommendations for
Getting to
“Capable”
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Provide educational material for both disorders Revise agency mission statement or develop a program service statement Implement one of the NYS-recommended standardized screening instruments Use assessment data to inform the treatment plan Allow co-occurring concerns to be expressed and discussed in all group and individual sessions Ensure that all groups include mental health and substance use content Offer a psycho-educational class on COD and a dual recovery group to create a “home” for co-occurring disorders in the program schedule Include both substance use and mental health treatment in discharge plans and provide sufficient medication to last until continuing care has been established Urge staff to enroll in FIT web-based learning Refer to and use TIP 42 and its associated training curriculum
Easy to Employ & Conserves Resources
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Clinic Name: Program Structure Program Milieu Clinical Process: Screening & Assessment Clinical Process: Treatment Continuity of Care Staffing Training
Improving Co-occurring Capability – Quick Guide
Your Name: Email: Phone: 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________ 1. _________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________
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Screening Instruments For mental disorders:
Modified MINI Screen
(MMS)
Mental Health Screening
Form III (MHSF III)
K6 Screening Scale (K6) For substance use disorders:
Modified Simple Screening Instrument for Substance Abuse
(MSSI-SA)
CAGE Adapted to Include Drugs (CAGE-AID)
Alcohol, Smoking, and Substance Involvement Screening Test
(ASSIST v3) – v3
Taskforce and Commissioners’ Recommendations
Assessment Domains
Presenting problem[s]
Current symptoms & functioning
Background
Individual history
Substance use
Mental health
Medical history
Mental status examination
Client perception[s]
Cultural and linguistic considerations
Supports & strengths
Diagnostic impressions on 5 DSM Axes Evidence-based Interventions For both disorders:
Approved medications For substance use disorders:
Evidence-based individual, group, couples, and family treatments –including
•
motivational
• • •
enhancement CBT 12-step facilitation behavioral couples & family therapy
•
contingency management For mental illness:
CBT, medication For serious mental illness:
Managing illness (IDDT, education, medication, CBT) family psychoeducation, supported employment, social skills training
Peer support 21
12 10 8 6 4 5 5 4 2 0 Training & Technical Assistance Activities Year 1 , Year 2, Year 3 (4 th Quarter of Year 3 is projected) Year 1 (Nov ’08 - Dec ’09) Year 2 (Nov ’09 - Oct ’10) Year 3 (Nov ’10 – Oct ’11) 11 8 165 200 3 100 100 4 86 3 50 50 0 0 0 DDCA[MH]T = Dual Diagnosis Capability in Addiction [Mental Health] Treatment Index 22
CEIC TA Services
have been provided in about
¾
of the state’s regions/counties 23
D
ual Disorder Capability
Enhanced
5 4,5 4
Closer to
Capable
than to Basic
3,5
Capable
3
2.70
2,5 2 2.48
2.50
3.06
2.53
2.76
3.09
(N=300)
2.47
1,5
Basic
1
Total Score
Program Structure Program Milieu Assessment Treatment Continuity of Care Staffing Training
Scores based on DDCA[MH]T = Dual Diagnosis Capability in addiction [Mental Health] Treatment Index 24
Enhanced
5 4.5
4
7
% 3.5
Capable
3 2.5
2
21
%
15
%
22
%
30
%
Dual Disorder Capability— Percentage Capable
43% are near or above Capable 1.5
6
%
Basic
1
Scores based on DDCA[MH]T = Dual Diagnosis Capability in Addiction [Mental Health] Treatment Index 25
Bi-annual OASAS EBP Survey
Surveydesigned to obtain EBP integration by implementation stages (Fixsen et al.) Added items on COD in collaboration with CEIC (and NKI) to assess COD practices Sent to all OASAS certified programs Rated on a 5- point implementation scale 5. Sustainability 4. Innovation 3. Implementation 2. Installation 1. Exploration Employs drop-down menu of additional questions to increase the accuracy of reporting Response rate 96% of all licensed programs
26
Local Services Plan (LSP) Survey Tool
(sample page) 27
Evidence-Based Practices and Evidence-Based Interventions: Level of Implementation
5 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0
Screening Assessment Integrated Services Motivational Interviewing Practices Cognitive Behavioral Therapy Level of Implementation Scale:
5 = Sustainability 4 = Innovation 3 = Implementation 2 = Installation 1 = Exploration 0 = Not applicable (hasn’t moved to implement at all)
Psychotropic Medication Contingency Management Interventions Mutual Self Help Group Behavioral Couples Therapy 28
Screening, Assessment, Integrated Services
Based on OASAS Survey (Level 5) 29
Evidence-Based Treatment for COD
Based on OASAS Survey (Level 5) About ¼ regularly employ evidence-based interventions 23% Total
Motivational Interviewing Cognitive Behavioral Therapy Contingency Management Behavioral Couples Therapy Mutual Self-help
30
Comparative Survey Results
31
Strategic Plan — Reach & Penetration
The strategic plan to reach & penetrate more than 1,000 out patient substance abuse & mental health clinics over 4 years
Direct (
“
hands-on
”
) Technical Assistance • DRCs • FIT • Regional / County Networks
amplifies
Direct TA
and promotes
Sustainability
32
Evaluation Plan
How will we know the system status?
1) Follow up DDCA[MH]T survey on representative sample 2) Follow up on OASAS survey — planned for 2012 3) Analysis combining these data sources (as briefly illustrated here) 4) Focus groups 5) Case studies 6) Brief web-based survey 33
Recent Developments
Integrated Services – Nassau County to integrate services both within clinics and across the service system Video – creating a video on building COD capability in the areas of Screening, Assessment and Evidence-Based Practices called “Getting to Capable” Manuscript – writing a descriptive study of the current status of the system for publication New Instrument – developing and refining an instrument to measure recovery-oriented services integration with NYAPRS New Instrument – developing and field testing an instrument with Dr. Mark McGovern to measure the degree to which primary health care services have been integrated with mental health and substance use interventions. This has particular significance for health care reform.
34
Summary
There exists a clear and increasingly positive picture of the status of OMH and OASAS outpatient clinics regarding evidence based practices and interventions
45% for screening 40% for assessment ⅓ for integrated services ¼ for evidence based interventions
The potential for advancement is greatest in the domains of Program Structure, Milieu, Treatment, Training and Continuity of Care, areas where certain improvements are considered to be fairly easy to achieve given the current status of staffing and resources
Transformation of the Service System may be said to occur when the majority of outpatient clinics are rated capable or above
OMH and OASAS outpatient clinics are moving toward a COD capable status
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Conclusion The project is significant in its:
Promise of improving the health of NYS residents with co-occurring conditions Potential to reduce health disparities Ability to inform allocation of resources Capacity to effect system transformation in the delivery of services Implications for health care reform: Identifying capable programs Illustrating methods and approaches for advancing integration
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Contact Information
Stanley Sacks, P H D, Director
Center for the Integration of Research & Practice (CIRP) & Center for Excellence in Integrated Care (CEIC) National Development & Research Institutes, Inc. (NDRI) 71 W 23rd Street, 8th Floor New York, NY 10010 TF 877.888.6677 tel 212.845.4400 fax 212.845.4650
www.nyshealth-ceic.org
www.ndri.org
Michael Chaple, P H D, Deputy Director
Center for the Integration of Research & Practice (CIRP) & Center for Excellence in Integrated Care (CEIC) National Development & Research Institutes, Inc. (NDRI) 71 W 23rd Street, 8th Floor New York, NY 10010 TF 877.888.6677 tel 212.845.4400 fax 212.845.4650
www.nyshealth-ceic.org
www.ndri.org
ChackuMathai, CPRP, Associate Executive Director
New York Association of Psychiatric Rehabilitation Services 1 Columbia Place, 2 nd Floor Albany, NY 12207 tel 518.436.0008 www.nyaprs.org
CEIC receives support (awards 2008-2496857 & 2009-3426912) from the New York State Health Foundation 37