NYAPRS 7NYAPRS 7thth Annual Executive Seminar on Systems Transformation Annual Executive Seminar on Systems Transformation

Presenter: Shelley Scheffler Ph.D., LCSWPresenter: Shelley Scheffler Ph.D., LCSW

Integrated Care SpecialistIntegrated Care Specialist

April 27-28 2011April 27-28 2011

New York City. N YNew York City. N Y

INNOVATIONS IN INTEGRATED INNOVATIONS IN INTEGRATED TREATMENT FOR CO-OCCURRING TREATMENT FOR CO-OCCURRING MENTAL HEALTH AND ADDICTION MENTAL HEALTH AND ADDICTION CONDITIONSCONDITIONS

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IntroductionIntroduction

Title: Title: Center for Excellence in Integrated Center for Excellence in Integrated CareCare

Funded by: Funded by: New York State Health FoundationNew York State Health Foundation

In coordination with:In coordination with: New York State (NYS) Offices of New York State (NYS) Offices of Mental Health (OMH) and of Mental Health (OMH) and of Alcoholism & Substance Abuse Alcoholism & Substance Abuse Services (OASAS)Services (OASAS)

Location:Location: NDRINDRI

Start Date:Start Date: November 1, 2008November 1, 2008

Period: Period: 4 years4 years

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•What does CEIC do?What does CEIC do?

Engages LeadershipEngages Leadership

Performs on-site assessmentsPerforms on-site assessments

Presents site reportsPresents site reports

Conducts provider forumsConducts provider forums

Builds collaborations and informal networksBuilds collaborations and informal networks

Holds Peer Recovery WorkshopsHolds Peer Recovery Workshops

Supplies ongoing support, guidance, Supplies ongoing support, guidance, and consultationand consultation

•Provides technical assistance Provides technical assistance (hands-on, intensive, and longitudinal)(hands-on, intensive, and longitudinal)

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WHY DO WE NEED TO MEASURE WHY DO WE NEED TO MEASURE CO-OCCURRING CAPABILITY?CO-OCCURRING CAPABILITY?

Generic terms like “integrated care” amount to “feel good” Generic terms like “integrated care” amount to “feel good” rhetoric but lack specificity.rhetoric but lack specificity.

Full integration (a clinician or program fully treating both Full integration (a clinician or program fully treating both mental health and substance use conditions) is often mental health and substance use conditions) is often presented as the only model of integration.presented as the only model of integration.

In reality, programs who’s history and culture are much closer In reality, programs who’s history and culture are much closer to substance abuse or mental health only are more likely to to substance abuse or mental health only are more likely to move towards more intermediate levels of integration (co-move towards more intermediate levels of integration (co-occurring capable)occurring capable)

Ultimately we will have a system with a range of levels of Ultimately we will have a system with a range of levels of integration (capable to enhanced ) integration (capable to enhanced )

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Building Co-occurring CapabilityBuilding Co-occurring Capability

Ad

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tio

n O

nly

Tx

CO

D C

apa

ble

CO

D C

apa

ble

CO

D E

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ance

d

Fully IntegratedFully Integrated

COD IntegratedCOD Integrated CO

D E

nh

anced

CO

D C

apa

ble

CO

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ble

Me n

t al Hea lt h

On

ly T

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OMH / OASAS COD TargetsOMH / OASAS COD Targets

• COD ScreeningCOD Screening

• COD Domains of AssessmentCOD Domains of Assessment

• COD Evidence Based PracticesCOD Evidence Based Practices

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Uses DDCA[MH]T

Samples individual clinics within regions

Employs direct onsite observation

Scores and reports on 7 domains separately and in total

Uses DDCA[MH]T

Samples individual clinics within regions

Employs direct onsite observation

Scores and reports on 7 domains separately and in total

•CEIC Assessment MethodsCEIC Assessment Methods

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Levels of CapabilityLevels of Capability(DDCAT or DDCMHT survey)(DDCAT or DDCMHT survey)

DIMENSIONS OF DIMENSIONS OF CAPABILITYCAPABILITY

LEVELS OF CAPABILITYLEVELS OF CAPABILITY

S.A./M.H.ONLY CAPABLE ENHANCEDS.A./M.H.ONLY CAPABLE ENHANCED

II Program StructureProgram Structure Program mission, structure and financing, format for Program mission, structure and financing, format for delivery of co-occurring services.delivery of co-occurring services.

IIII Program MilieuProgram Milieu Physical, social and cultural environment for persons Physical, social and cultural environment for persons with mental health and substance use problems.with mental health and substance use problems.

IIIIII Clinical Process: Clinical Process: AssessmentAssessment

Processes for access and entry into services, Processes for access and entry into services, screening, assessment & diagnosis.screening, assessment & diagnosis.

IVIV Clinical Process: Clinical Process: TreatmentTreatment

Processes for treatment including pharmacological and Processes for treatment including pharmacological and psychosocial evidence-based formats.psychosocial evidence-based formats.

VV Continuity of CareContinuity of Care Discharge and continuity for both substance use and Discharge and continuity for both substance use and mental health services, peer recovery supportsmental health services, peer recovery supports..

VIVI StaffingStaffing Presence, role and integration of staff with mental Presence, role and integration of staff with mental health and addiction expertise, supervision processhealth and addiction expertise, supervision process

VIIVII TrainingTraining Proportion of staff trained and program’s training Proportion of staff trained and program’s training strategy for co-occurring disorder issues.strategy for co-occurring disorder issues.

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• Dual Disorder CapabilityDual Disorder Capability

•Total Score•Program Structure

•Program Milieu

•Screening & Assessment

•Treatment •Staffing •Training•Continuity of Care

•2.71•2.5 •2.53

•3.05

•2.53•2.74

•3.06

•2.52

•closer to Capable than to

Basic

•EnhancedEnhanced

•CapableCapable

•BasicBasic

•Scores based on DDCA[MH]T = Dual Diagnosis Capability in addiction [Mental Health] Treatment Index

• (N=251)

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ObservationsObservations

The outpatient system has moved away from addiction and mental health The outpatient system has moved away from addiction and mental health only status, and is moving towards co-occurring capable levels of care.only status, and is moving towards co-occurring capable levels of care.

The outpatient mental health system is repositioning itself to provide The outpatient mental health system is repositioning itself to provide services for mild to moderate levels of substance abuse. services for mild to moderate levels of substance abuse. (Quadrant 2: (Quadrant 2: high mental health – mild to moderate substance abuse)high mental health – mild to moderate substance abuse)

The outpatient substance abuse treatment system is repositioning itself The outpatient substance abuse treatment system is repositioning itself to provide services for mood and anxiety conditions. to provide services for mood and anxiety conditions. (Quadrant 3: high (Quadrant 3: high substance abuse – mild to moderate mental health)substance abuse – mild to moderate mental health)

Consumers with high severity of mental health and addiction Consumers with high severity of mental health and addiction (Quadrant (Quadrant 4: high substance abuse – high mental health)4: high substance abuse – high mental health) still have very few service still have very few service options, however more integrated collaborations between substance options, however more integrated collaborations between substance abuse and mental health clinics have the potential to address this abuse and mental health clinics have the potential to address this significant gap. significant gap.

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Issues for consideration Issues for consideration

With an average score of 2.71 the OASAS and OMH outpatient system is moving With an average score of 2.71 the OASAS and OMH outpatient system is moving towards a co-occurring capable level of service integration.towards a co-occurring capable level of service integration.

The two systems are remarkably close in their capability scores-The two systems are remarkably close in their capability scores-

2.76 OASAS, 2.67 OMH- the staffing domain is the only area with2.76 OASAS, 2.67 OMH- the staffing domain is the only area with

any statistical significance.any statistical significance.

Its now feasible to consider that in time, a baseline of co-occurring capable is Its now feasible to consider that in time, a baseline of co-occurring capable is achievable across the two systems.achievable across the two systems.

As programs who are currently in the midrange ( 2.71), move to capable status there As programs who are currently in the midrange ( 2.71), move to capable status there will be further movement of those currently capable (3.00 -3.66), to more enhanced will be further movement of those currently capable (3.00 -3.66), to more enhanced levels of care, however greater resources are required to accomplish the latterlevels of care, however greater resources are required to accomplish the latter

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Issues for considerationIssues for consideration

Programs who have undertaken a measure of their current co-Programs who have undertaken a measure of their current co-occurring capability using the DDCAT or DDCMHT are in a better occurring capability using the DDCAT or DDCMHT are in a better position to target specific areas requiring co-occurring competency position to target specific areas requiring co-occurring competency building training.building training.

Programs who have undertaken a measure of their current co-Programs who have undertaken a measure of their current co-occurring capability using the DDCAT or DDCMHT and then implement occurring capability using the DDCAT or DDCMHT and then implement recommendations to increase capability can use the same tool to recommendations to increase capability can use the same tool to guide their evaluation of outcomes of changes in their capabilityguide their evaluation of outcomes of changes in their capability

The results of each survey provides individual programs with possible The results of each survey provides individual programs with possible recommendations for increasing their co-occurring capability.recommendations for increasing their co-occurring capability.

The aggregate trends that emerge from all programs surveyed across The aggregate trends that emerge from all programs surveyed across the state will assist decision makers in identifying larger issues of the state will assist decision makers in identifying larger issues of systemic change that could be considered for advancing capability.systemic change that could be considered for advancing capability.

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Key issues for building capabilityKey issues for building capability

Not all programs have implemented a recommended co-occurring Not all programs have implemented a recommended co-occurring screener and when implemented many programs lack a clear protocol screener and when implemented many programs lack a clear protocol when a positive cut-off score is determined.when a positive cut-off score is determined.

Stage-wise assessment and treatment has not been incorporated into Stage-wise assessment and treatment has not been incorporated into most programs.most programs.

Specialized interventions with either mental health or substance abuse Specialized interventions with either mental health or substance abuse content are variable in treatment schedules and in a number of cases non-content are variable in treatment schedules and in a number of cases non-existent.existent.

The systematic inclusion of peer recovery support positions for patients The systematic inclusion of peer recovery support positions for patients with cod is a significant issue for most programs with the majority rating with cod is a significant issue for most programs with the majority rating poorly on the surveypoorly on the survey

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Key issues for building capabilityKey issues for building capability

Out patient programs vary considerably from those that offer core Out patient programs vary considerably from those that offer core components of treatment to those where treatment is driven almost components of treatment to those where treatment is driven almost entirely by individual clinician preference. In the case of the latter it entirely by individual clinician preference. In the case of the latter it is proving far more difficult to implement programmatic changeis proving far more difficult to implement programmatic change

The implementation of recommended co-occurring evidence-based The implementation of recommended co-occurring evidence-based practices at a programmatic level is at its infancy. This also is practices at a programmatic level is at its infancy. This also is consistent with a system that is moving from “only to capable”consistent with a system that is moving from “only to capable”

For many programs the next step in capability building will be to For many programs the next step in capability building will be to increase either the mental health or the substance abuse content of increase either the mental health or the substance abuse content of their existing treatment regimes rather than the implementation of a their existing treatment regimes rather than the implementation of a specific cod evidence based practice.specific cod evidence based practice.

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Contact InformationContact Information

Center for Excellence in Integrated Care Center for Excellence in Integrated Care (CEIC)(CEIC)

71 W 23rd Street, 8th Floor71 W 23rd Street, 8th Floor

New York, NY 10010New York, NY 10010

tel 212.845.4400 tel 212.845.4400 fax 212.845.4650 fax 212.845.4650

www.nyshealth-ceic.orgwww.nyshealth-ceic.org

•"CEIC receives support (awards 208-2496857 & 2009-3426912) from the New York State Health Foundation (NYSHealth)."•"CEIC receives support (awards 208-2496857 & 2009-3426912) from the New York State Health Foundation (NYSHealth)."•"CEIC receives support (awards 208-2496857 & 2009-3426912) from the New York State Health Foundation (NYSHealth)."•"CEIC receives support (awards 208-2496857 & 2009-3426912) from the New York State Health Foundation (NYSHealth)."

• CEIC receives support (awards 208-2496857 & 2009-3426912) • from the New York State Health Foundation (NYSHealth)