Transcript Document

The American Indian/Alaska Native National Resource Center
for Substance Abuse and Mental Health Services
Best Practices in Native
Communities: Strengthening Our
System of Care
The Forum
San Diego. California
June 27, 2005
Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD
Laura Loudon, MS Toma Timothy Michelle Singer
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For information, contact us at
503-494-3703
E-mail
Dale Walker, MD
[email protected]
Or visit our website:
www.oneskycenter.org
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Best Practices Overview
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Disconnect Between
Drug/Alcohol/ Mental Health
• Professionals are undertrained in at least one
of the domains
• Patients are underdiagnosed
• Patients are undertreated
• None integrates well with medical and social
service
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Difficulties of Program
Integration
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Separate funding streams and coverage gaps
Agency turf issues
Different treatment philosophies
Different training philosophies
Lack of resources
Poor cross training
Consumer and family barriers
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Best Practices: Historical
Evolution
• Agencies: IOM, I.H.S., NIAAA, NIDA,
NIMH, SAMHSA, NIAAA, VAMC
• Businesses: Managed care, economics
• Quality care, effectiveness care
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Spectrum of Intervention Responses
Thresholds for Action
No
Problems
Mild
Problems
Moderate
Problems
Severe
Problems
Treatment
Brief Intervention
Universal/Selective
Prevention
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Alcohol/Drug Treatment Core
Components and Comprehensive
Services
Medical
Financial
Housing &
Transportation
Core
Treatment
Intake
Assessment
Child
Care
Treatment
Plans
Group/Individual
Counseling
Abstinence
Based
Pharmacotherapy
Mental
Health
Urine
Monitoring
Vocational
Case
Management
Continuing
Care
Educational
Self-Help
(AA/NA)
Family
AIDS /
HIV Risks
Legal
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Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)
How Are Evidence-Based
Practices Documented?
Gold Standard
• Multiple randomized clinical trials
Silver Standard
• Consensus reviews of available science
Bronze Standard
• Expert opinion based on clinical observation
(Drake, et al. 2001. Implementing evidence based practices in routine mental health service
settings. Psychiatric Services, 52, 179 – 182)
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Three Types of Treatment Have
Demonstrated Similar Success Rates
Treatments
• Cognitive behavior therapy
– Learning skills to cope with
situations that precipitate drinking
• 12-step programs
Success Rates
At 1 Year
• Abstinent 85% of days
(vs. 20%–30% of days at
start of study)
– Alcoholism is a disease
– AA involvement
• Motivational-enhancement therapy
At 3 Years
• 2/3 still abstinent
– Motivational interviewing outlined
in guidebooks
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Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607
A Selected Sample of Manuals
• Time Out! For Me - Workshop for Women
• Time Out! For Men
• Cognitive Behavior Therapy for Adolescents
• Multidimensional Family Therapy
• Enhancing Motivation for Change
• Mapping New Roads to Recovery
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Nine Steps to Help Prevent LongTerm Disability from Unhealthy
Alcohol/Drug Use
1. Gather information
2. Express concern
3. Provide feedback
6. Know local referral
options
7. Reinforce self worth
8. Assist with a plan
9. Follow up
4. Express empathy
5. Offer help
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Integrated Treatment
“Any mechanism by which treatment
interventions for co-occurring disorders are
combined within the context of a primary
treatment relationship or service setting.”
-CSAT
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Agencies Involved in B.H. Delivery
1. Indian Health Service (IHS)
A. Mental Health
B. Primary Health
C. Alcoholism / Substance Abuse
2. Bureau of Indian Affairs (BIA)
A. Education
B. Vocational
C. Social Services
D. Police
3. Tribal Health
4. Urban Indian Health
5. State and Local Agencies
6. Federal Agencies: SAMHSA, VAMC
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American Indians and Alaska
Natives
• Have same health disorders as
general population
• Greater prevalence
• Greater severity
• Much less access to Tx
• Cultural relevance more challenging
• Social context disintegrated
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Behavioral Health Issues
• Addiction
– Crow Nation
• Suicide
– Standing Rock
– Red Lake
• Domestic Violence
• Co morbidity
– Across Regions
60.0
50.0
48.7
40.0
30.0
20.0
20.0
15.0
10.4
10.0
7.3
6.7
0.0
Alcoholism
Suicides
Homicides
19 people.
Chart indicates deaths per 1000
Blue = AI, Burgundy = U.S. Average
Different goals
Resource silos
One size fits all
Activity-driven
How is it working?
(Carl Bell, 7/03)
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Culturally
specific
Best
Practice
Outcome
driven
Integrating
resources
We need Collaboration, Integration, and
Synergy : Community Mobilization
(Carl Bell, 7/03)
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Definitions:
Indigenous Knowledge
• Is local knowledge unique to a given culture
or society; it has its own theory, philosophy,
scientific and logical validity, which is used as
a basis for decision-making for all of life’s
needs.
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Definitions:
Traditional Medicine
• The sum total of health knowledge, skills and
practices based upon theories, beliefs and
experiences indigenous to different
cultures…used in the maintenance of health.
WHO 2002
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Definitions:
Evidence-based Practices
• Interventions that show consistent scientific
evidence of improving a person’s outcome of
treatment and/or prevention in controlled
settings.
SAMHSA 2003
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Definitions:
Best Practices
• Examples and cases that illustrate the use of
community knowledge and science in
developing cost effective and sustainable
survival strategies to overcome a chronic
illness.
WHO 2002
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World Conference on Science
A partnership begins!
• Recommended that scientific and indigenous
knowledge be integrated in interdisciplinary
projects dealing with culture, environment
and chronic illness.
1999
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ID Best Practice
Best Practice
Clinical/Services
Research
Mainstream
Practice
Traditional
Healing
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Circle of Care
Traditional
Healers
Primary Care
A&D
Programs
Best
Practices
Child &
Adolescent
Programs
Boarding
Schools
Colleges &
Universities
Prevention
Programs
Emergency
Rooms
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Community Mobilization
Partnered Collaboration
Grassroots
Groups
Community-Based
Organizations
Treatment-Education-Research
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