Integrated Dual Diagnosis Services:Implementation

and Program Maintenance

Randi Tolliver, PhD, CADC

Illinois Co-Occurring Center for Excellence

www.illinoiscoce.org

“Co-occurring disorders may include any combination of two or more substance abuse disorders and mental disorders identified in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). There are no specific combinations of….disorders that are defined uniquely as co-occurring disorders.”

In “A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders”

SAMHSA Definition

Integrated Dual Diagnosis Services

Improve quality of life

Promote hopeful interactions

Utilize biopsychosocial treatments

Promote consumer and family involvement in service delivery

Promote and increase stable housing

Promote a recovery concept

Utilize Recovery Management and/or Recovery Support Specialists

Increase continuity of care

Promote employment as an expectation

Increase independent living

Integrated Dual Diagnosis Services

Integrated Dual Diagnosis Services

Co-morbidity is an expectation, not an exception.

There is no one type of dual diagnosis program or intervention.

Motivational enhancement strategies

Substance abuse and mental health counseling services

Integrated Dual Diagnosis Services

Multidisciplinary teams

Access to comprehensive services

Participation in self-help groups

Pharmacological treatments

Interventions to promote health and well-being

Evidence-Based Practice

Two Directions in EBP

Evidence-Based Interventions: • EB Guidelines, EB Practices, Empirically-

supported (validated) Treatments

Evidence-Based Process for decision-making:• EB Process, EB Individual Practice

Evidence-Based Guidelines (EBG)

• Different methods for designing guidelines: global subjective judgment or consensus-based, outcomes based, preference based, expert opinion, evidence based

• Importance of explicit, evidence-based process in developing guidelines

Evidence-Based Process (EBP)

• EB Process is a way of doing practice which involves an individualizing process whereby evidence is used to make collaborative decisions with clients and caregivers. (Mullen, 2004)

• EB Process is the integration of best research evidence with clinical expertise and patient values (Sackett et al., 2000).

Systems of Care

Recovery Oriented Systems of Care

Comprehensive, Continuous, Integrated Systems of Care Model

• Focused on recovery

• Comprehensive

• Be viewed as seamless by the consumer

• Involve multiple systems

Adapted from SAMHSA Report To Congress 2002

Integrated Services & Integrated Systems

• Integrated Services– Designed to improve access and use of all

needed services and resources

• Integrated Systems– Designed to change service delivery for a

specific population

SAMHSA Report To Congress 2002

Systems Integration

•Success occurs when a comparable emphasis is placed on integrated services

•Systems integration does not necessarily require the creation of new services or agencies

•Should be measured by system-level and consumer level outcomes

SAMHSA Report To Congress 2002

Recovery-Oriented Systems of Care

• Support person-centered and self-directed approaches to care that build on the strengths and resilience of individuals, families, and communities to take responsibility for their sustained health, wellness and recovery from alcohol and drug problems.

National Summit on Recovery Conference report, 2005.

ROSC System of Care Elements

• Person-centered

• Family and other ally involvement

• Individualized and comprehensive services across the lifespan

• Systems anchored in the community

• Continuity of care

National Summit on Recovery Conference report, 2005.

ROSC System of Care Elements

• Partnership-consultant relationships• Strength-based• Culturally responsive• Responsiveness to personal belief

systems• Commitment to peer recovery support

services• Inclusion of the voices and experiences of

recovering individuals and their familiesNational Summit on Recovery Conference report, 2005.

ROSC System of Care Elements

• Integrated services

• System-wide education and training

• Ongoing monitoring and outreach

• Outcomes-driven

• Research-based

• Adequately and flexibility financed

National Summit on Recovery Conference report, 2005.

Comprehensive, Continuous, Integrated Systems of Care Model

(CCISC)

•4 Basic Characteristics4 Basic Characteristics

•8 Principles of Treatment8 Principles of Treatment

•12 Steps of Implementation12 Steps of Implementation

Kenneth Minkoff, MDKenneth Minkoff, MD

Four Basic Characteristics of CCISC

1. System Level Change

2. Efficient Use of Existing Resources

3. Incorporation of Best Practices

4. Integrated Treatment Philosophy

Kenneth Minkoff, MDKenneth Minkoff, MD

Eight Principles of Treatment of CCISC

1. Dual diagnosis is an expectation, not an exception.

2. All people diagnosed with a COD are not the same.

3. Empathic, hopeful, integrated treatment relationships

4. Case management must be balanced with empathic detachment, expectation, contracting, consequences, and contingent learning.Kenneth Minkoff, MDKenneth Minkoff, MD

Eight Principles of Treatment of CCISC

5. Both disorders should be considered primary.

6. Both mental illness and addiction can be served

within a similar philosophical framework with parallel phases of recovery.

7. There is no single correct intervention for COD.

8. Clinical outcomes for COD must also be individualized. Kenneth Minkoff, MDKenneth Minkoff, MD

Twelve Steps of Implementation of CCISC

1. Integrated system planning process

2. Formal consensus on CCISC model

3. Formal consensus on funding the CCISC model

4. Identification of priority populations, and locus of responsibility for each

5. Development and implementation of program standards

6. Structures for intersystem and interprogram care coordination Kenneth Minkoff, MDKenneth Minkoff, MD

Twelve Steps of Implementation of CCISC

7. Development and implementation of practice guidelines

8. Facilitation of identification, welcoming, and accessibility

9. Implementation of continuous integrated treatment

10. Development of basic dual diagnosis capable competencies for all clinicians

11. Implementation of a system wide training plan 12. Development of a plan for a comprehensive

program array Kenneth Minkoff, MDKenneth Minkoff, MD

Organizational Environment

Differences: Treatment

philosophy Treatment

practice Relationships

Common Common ground:ground: Values and Values and principles principles Guidelines Guidelines Outcome Outcome measuresmeasures Vocabulary Vocabulary

Basic competenciesBasic competencies

Organizational Change

Understanding the organization’s model

Multi-level organizations• Mutual and conflicting needs• Traditional versus innovative ways of

communicating• Systems tend to resist substantial

change

Adapted from Hendrickson, E. L (2006)

Adopting Evidence Based Practices in an Organization

• Address organizational and clinical elements in development and implementation.

• Engage and prepare the organization, programs, and staff for changes.

• Develop a working partnership with the treatment team.

• Promote staff ownership for the practices.

Program Development

Utilize evidence-based or best practices

Utilize a competency-based perspective

Employ recovery support specialists

Develop a plan to address housing needs

Employ employment specialists

Program Development

Develop policy & procedures for program operations

Develop a clear understanding of target population and program goals

Develop a marketing strategy that will ensure adequate numbers of consumers are engaged

Program Development

Develop a realistic time frame for hiring and training staff

Establish a functional and clear admission and referral process

Allow easy accessibility to program services across the continuum of care

Questions to Consider for Development and Implementation

Currently, which co-occurring treatment services are being offered to which consumers?

Where in the continuum of care are the services being offered?

Do current services demonstrate the qualities of “effective” services?

Do the services meet the needs of the community?

SAMHSA Tip 42

Questions to Consider

What resources are available?

What are the barriers to implementing the EBP?

What are the priorities?

What is the capacity of the agency to implement comprehensive, integrated services?

Questions to Consider

What are the core competencies needed for staff to provide effective services?

What services are currently offered?

What modifications will need to be made in the evidence based practice?

Implementation Challenges

Physician or psychiatrist staffing

Physical resources

Billing and reimbursement issues

McGovern, Xie, et. al. (2006).

Implementation Challenges

Identifying and responding to gaps in workforce competencies, certifications, and licensure

Addressing increases in staff concern related to changes in roles and responsibilities

Addressing discrepancies in record keeping

Implementation Challenges

Addressing organizational structure and policies

Resolving differences in treatment philosophies

Establishing a cohesive multidisciplinary team

Implementation Challenges

• Developing treatment manuals, tool kits, online support.

• Addressing the organizational components: Do we modify the intervention or modify environment?

• Assessing fidelity to EBP model through use of fidelity measures.

Fidelity and Indexes

General Organization Index (GOI)

Integrated Dual Diagnosis Treatment (IDDT) Fidelity Scale

Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index& Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index

Motivational Interviewing Treatment Integrity (MITI)

General Organizational Index

1. Program Philosophy2. Eligibility/ Consumer Information3. Penetration4. Assessment5. Individualized Treatment Plan6. Individualized Treatment7. Training8. Supervision9. Process Monitoring10. Outcome Monitoring11. Quality Assurance12. Consumer Choice Regarding Service Provision

IDDT Fidelity Scale

1. Multidisciplinary Team2. Stage-Wise Interventions3. Access to Comprehensive DD Services4. Time-Unlimited Services5. Outreach6. Motivational 7. Substance Abuse Counseling8. Group DD Treatment9. Family Psychoeducation on DD10. Participation in Alcohol & Drug Self-Help Groups11. Pharmacological Treatment12. Interventions to Promote Health13. Secondary Interventions to Substance Abuse

Treatment Non-Responders

Dual Diagnosis Capability in Addiction Treatment

(DDCAT) Index

1. Program Structure2. Program Milieu3. Clinical Process: Assessment4. Clinical Process: Treatment5. Continuity of Care6. Staffing7. Training

McGovern et al. (2006).McGovern et al. (2006).

Assessing Motivational Interviewing

• A behavioral coding system

• Provides an answer to the question: How well or poorly is an individual using Motivational Interviewing strategies?

• Provides data that can be used to increase Motivational Interviewing skills.

Motivational Interviewing Fidelity• Training Protocol

– Awareness building– Knowledge-focused training– Skills-based training– Abilities training

• Clear and focused supervision• Taped Motivational Interviewing Assessment

sessions• Coding protocol• Feedback and instruction for improving skills

National Institute on Drug Abuse, (2001).

Program Commitment Plan

Specific statements of services to be implemented

Identification of individual(s) to monitor implementation

Identification of ways to measure effectiveness of services

Method for implementing servicesAdapted from Hendrickson, E. L (2006)

Program Commitment Plan

Development of timeline for implementation

Process to determine effectiveness of plan implementation

Method for ongoing review and modification of the plan

Adapted from Hendrickson, E. L (2006)

Implementation Index

• Organizational and Contextual Factors

• Implementation Strategies

• Program Culture

• Staffing & Training

• Evaluation

• Other Implementation Activities

McGovern et al. (2006).McGovern et al. (2006).

Paradigm Shifts

Interactive Staff Training

•Focus is on the team rather than the individual

•Goal is the development of a user-friendly program

Interactive Staff Training

• Work with team members from several teams.

• Meet with team on site.

• Meet monthly for one hour.

• 1 year commitment.

September is National Alcohol and Drug Addiction

Recovery Month

Real People, Real Recovery

Celebrate with us in September 2008.

• www.recoverymonth.gov

• www.illinoiscoce.org

References

• Corrigan, P.W. & McCracken, S.G. (1997). Interactive staff training: Rehabilitation teams that work. New York: Plenum.

• Evans, K. & Sullivan, J. M. (2001). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser (2nd Ed.). New York: Guilford.

• Gibbs, L.E. (2003). Evidence-based practice for the helping professions: A practical guide with integrated multimedia. Pacific Grove, CA: Brooks/Cole-Thompson Learning.

• Hendrickson, E. L (2006). Designing, Implementing, and Managing Treatment Services for Individuals with Co-Occurring Mental Health and Substance Use Disorders: Blueprints for Action. Binghampton, NY: Haworth Press.

References• Hendrickson, E. L. & Schmal, M. (1993). Dual Disorders

Page, TIE Lines, 10 (3), 11.

• McGovern, M. P., Giard, J., Brown, J., Comaty, J., & Riise, K. (2006). The Dual Diagnosis Capability in Addiction Treatment (DDCAT): A Toolkit for Enhancing Addiction Only Service (AOS) Programs and Dual Diagnosis Capable (DDC) Programs. Unpublished manuscript, Dartmouth Medical School.

• McGovern, M.P., Xie, H., Segal, S. R., Siembab, L., & Drake, R. E. (2006). Addiction treatment services and co-occurring disorders: Prevalence estimates, treatment practices, and barriers. Journal of Substance Abuse Treatment (31), 276-275.

References• Minkoff, K., & Cline, C. A. (2004). 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, 727-743.

• Mueser, K.T., Noordsy, D.L., Drake, R.E., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York: Guilford.

• Regier, D. A., Farmer, M. E., Rae, D. S., et al. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) Study. Journal of American Medical Association, 264, 2511-2518.

References

• Sackett, D.L., Richardson, W.S., Rosenberg, W. M. C., & Haynes, R. B.  (2000). Evidence-Based Medicine: How to Practice and Teach Evidence Based Medicine (2nd ed.). London: Churchill-Livingstone.

• http://www.samhsa.gov/reports/ co_occur_home.htm– SAMHSA Report to Congress on The Prevention and

Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders