California County Co-occurring Disorders Policy Academy · in the development of implementation strategies for systems, facilitated the meeting and provided content technical assistance

California County Co-occurring Disorders Policy Academy • Summary Report of County Feedback FormsCalifornia Institute for Mental Health • January 2005 1

California CountyCo-occurring Disorders

Policy AcademyDecember 8, 2004

Summary Report ofCounty Feedback Forms

A publication of theCALIFORNIA INSTITUTE FOR MENTAL HEALTH

California County Co-occurring Disorders Policy Academy • Summary Report of County Feedback Forms2 California Institute for Mental Health • January 2005

On December 8, 2004, The California Institute forMental Health (CIMH), with representatives fromAlcohol and Drug Program Institute (ADPI), and co-sponsorship by the California Department of MentalHealth (DMH), Department of Alcohol and DrugPrograms (ADP), County Alcohol and DrugProgram Administrators Association of California(CADPAAC), and California Mental HealthDirectors Association (CMHDA), organized a PolicyAcademy for California counties. Participantsdiscussed the development of county-level systemapproaches for providing integrated services toindividuals and families with co-occurring mentalhealth and substance abuse conditions.

Drs. Christie A. Cline and Kenneth Minkoff ofZiaLogic, who are nationally recognized as expertsin the development of implementation strategiesfor systems, facilitated the meeting and providedcontent technical assistance. ZiaLogic has workedwith California’s Co-occurring Disorder TaskForce and other state agencies in applying for aco-occurring disorders state infrastructure grant(COSIG) from the U.S. Department of Health andHuman Services’ Substance Abuse and MentalHealth Services Administration (SAMHSA).ZiaLogic encouraged the Policy Academy tofurther the aims of the COSIG, although the grantitself was not funded last year.

All 58 California counties were invited to sendrepresentatives to the Policy Academy. In all, 47

Background

counties (plus the City of Berkeley) participatedin the meeting. After a brief overview of theComprehensive Continuous Integrated System ofCare model (CCISC), developed by ZiaLogic’sDr. Minkoff, presentations were made byrepresentatives from the counties of Humboldt,Los Angeles, and San Diego on their progress indeveloping systemwide integrated services.Presenters emphasized strategies for collaborationand planning, as well as models for policy,program, and clinician development, anddiscussed lessons learned. Following thepresentations, the county teams met in groups,based on their county’s size, to share informationon activities, barriers, and possible solutions. Eachcounty group then reported back to the largergroup, and ZiaLogic facilitated a discussion toarticulate lessons learned, as well as to distill a setof recommendations on how the state could workwith the counties to improve services integration.

At the end of the day, each county team wasrequested to submit both a conference evaluation,and a feedback form describing their currentstructure, activities, and level of priority, as wellas future plans and communications with the state.This report is based largely on the data submittedin those forms, but is aligned with the discussionsthat occurred at the conclusion of the PolicyAcademy.

California CountyCo-occurring Disorders

Policy AcademyDecember 8, 2004

Summary Report ofCounty Feedback Forms


Target Audiencesof this Report

This report is intended to provide summaryinformation to DMH and ADP from Californiacounties regarding recommendations forproviding support to current county efforts. Thereport is directed to the California State PolicyAcademy Team (funded by SAMHSA), which metin Washington, D.C., January 11-13, 2005, todetermine how the Policy Academy Team (whichhas state, county, provider, and stakeholderrepresentation) can most effectively align state andcounty activities. In addition, the report isdesigned to assist the county director associationsin organizing advocacy, support, and technicalassistance for integrated services development totheir members. And, finally, the report is intendedto assist CIMH and ADPI plan for funding andactivities in the coming year to work in partnershipwith each other (within the current organizationalstructure at the state level), and with counties toimprove the integration of services throughout theCalifornia behavioral health delivery system foradults and children.

Data AnalysisZiaLogic performed a qualitative analysis of the

aggregate information provided in the feedbackforms. A total of 36 forms were submitted, pluspresentation information from Los Angeles,representing 38 counties of the 46 in attendance.No information is available regarding differencesin integrated services planning from among thosethat did not attend, or whether the counties thatsubmitted feedback forms are significantlydifferent from those that did not. Nonetheless,the feedback represents information from 66percent of all counties, and attendees represented80 percent of all counties.

The data were analyzed to determine thefollowing elements: organizational structure, level

of priority for integrated services, stage of changeregarding system planning and implementation,existence of an integrated planning structure orformat, types of activities accomplished and/orplanned, and suggestions to the state. In addition,an effort was made to analyze the combinedpicture from the feedback forms and from PolicyAcademy discussions to distill an impression ofspecific strengths and needs for assistance withinthe system.

Organizational structure is arbitrarily dividedinto three types: (1) merged (mental health andaddiction combined into an integrated behavioralhealth department); (2) mixed (mental health andaddiction combined into an integrated behavioralhealth department but retaining separatedivisions); and (3) separate (mental health andaddictions existing as separate entities, either asfull-fledged departments or within larger healthand human services agencies in which they mightbe on par with other departments, e.g. publichealth, and/or operate as relatively autonomousdivisions). However, the boundaries betweenthese three types are not always clean, and manysystems exist in between merger and mixed, ormixed and separate, so it became a judgment callhow to define them.

Prioritization is based on self-report in the form.Stage of change is based on extrapolation from thedescriptions in the report—contemplation impliesthat the county was considering initiating a changeprocess with no immediate plan, preparationimplies an immediate plan to begin but not yetstarted, early action implies recently moving tosystem-level planning with some start-upactivities, action implies being in the middle of asystem change process in integrated services.Regular planning is based on whether the formdescribed a particular team or meeting involvingrepresentation from both mental health andaddictions with a consistent focus on this issue.Activities and suggestions are distilled fromdescriptions in the forms, and are simplifiedsummaries of complex comments and ideas.


FindingsOrganizational structures: merged 7, mixed 14,

separate 17. Almost all of the separate structureswere part of an umbrella health and/or humanservices agency.

Prioritization: very high 7, high 24, above-average or inconsistently high 3, medium 1, nothigh 1, not reported 2. High prioritizationextended across all types of structure.

Stage of change: action 17, early action 5,preparation 13, contemplation 3. Action extendsacross all types of structures. None of the threepresenters is or plans to be merged, but the countythat appears the furthest in its development(Stanislaus) has a merged structure.

Planning structure: 22 counties reported havingsome kind of regular systemwide meetingempowered to create a plan for integrated services;7 were mixed, in that the meetings were irregular,just beginning, in only part of the system (e.g.children), at a low level, or not focused. A total ofnine counties had no regular meetings, but almosthalf of those were planning to initiate a plan.

Activities: In line with the presenters, many ofthe counties commented on the importance of along-range approach (one county mentioned a 12-year task force), building collaborativerelationships at all levels, mutual support andvalidation between partners, and ongoing staffdevelopment through formal cross training,supervision and case conferencing. A total of 6counties (mostly smaller) reported some type ofco-location strategy for clinical staff. A number ofcounties mentioned strategic planning anddesigning functionally organized and/orprinciple-driven systems of care. Very few,however, had an organized systems approach todiscuss change at all levels. Most counties had notyet developed guidelines or policies andprocedures, and several expressed interest inexamining San Diego’s welcoming and fundingpolicy. Many smaller counties discussed co-occurring disorder groups. Large and smallcounties reviewed pilot projects and examined

initiatives across a wide range of activities,including AB 2034, IDDT toolkit implementation,stage matched treatment, screening, Proposition36, youth (children’s system of care) and youth intransition, child welfare reform, access and crisisintervention. A significant number of countiesdiscussed co-occurring disorders and integratedservice development, including systemdevelopment, in Proposition 63 planning. Sixcounties mentioned past, current, or future plansto obtain formal consultation or technicalassistance on systems approaches to developingintegrated services.

Suggestions to state. A total of 16 counties agreedthat the state should encourage and supportintegrated planning and formal collaborationsbetween mental health and addictions at thecounty level. This included very generalsuggestions, such as “anything to help us getstarted,” to very specific suggestions, such asproviding joint ADP-DMH policy directioncomunicate one system, require formalcollaboration in county plans, make integratedservices development a required feature of QIplans, include integrated planning for co-occurring service capacity development as afeature of Proposition 63 planning, provide accessto technical assistance for strategic planning andsystem development. At the end of the PolicyAcademy meeting, 21 counties agreed the stateshould provide clearer instructions on how to usecurrent funding streams, particularly MediCal, tosupport integrated treatment, and how tominimize any administrative burden attached tothat. Five counties suggested it would be helpfulto reduce administrative burden attached toreporting data, and one mentioned alignment ofsite visits. Five counties suggested help withscreening, assessment, and outcome tools. Fourcounties encouraged support of cross training andintegrated human resource development. Inaddition, participants discussed the need forfunding of medical detoxification, jail diversion,supported employment and housing, andcontinued support for Proposition 36.


Qualitative Assessment1. Counties have shown an impressive level of

interest and a high degree of prioritizationfor implementing system approaches tointegrated services.

2. Considerable activity is taking place, or aboutto take place, at the county level. Sixtypercent of reporting counties have a regularplanning process, and most of the rest aredeveloping one. All but three counties havebegun, or are about to begin, some kind ofsystems integration planning effort .

3. Most counties have been involved with thisfor many years at the clinical program orproject level, rather than at the systems level,and are starting, or just about to start, system-level planning and implementation.However, a few counties are well intodeveloping either their strategic design orimplementation efforts. Stanislaus, SanDiego, Los Angeles, Humboldt, SanFrancisco, San Joaquin, and Butte are amongthe counties that stood out by self report.These counties may be able to provideassistance to their peers who are not as faralong.

4. The counties that have made the mostprogress tend to talk about how their servicesare organized to achieve particular principlesof treatment and/or to provide particularfunctions, rather than the services beingorganized to fit into preordainedadministrative, fiscal, or clinical boxes.

5. Although a high percentage of the countiesare currently engaged in, or about to beengaged in this effort, many differences existbetween counties in their approaches toachieving the goal of improving integratedservices. This would suggest that a state-levelinitiative should be designed to utilize toolsor models that can be adapted to thestructure, needs, and priorities of verydiverse local systems in order to achieve

common system outcomes, rather than tryingto make every county comply to the samemethods.

6. Counties in the earlier stages of changeappear to require more assistance from thestate in activities related to getting started,including incentives for engaging inintegrated planning, technical assistance withorganizing an interagency change process,and permission to use existing funding moreflexibly to support integrated treatment.Those counties that are further along aremore likely to require assistance with“implementation activities,” such as policies,practice development, human resourcedevelopment, quality improvement andevaluation, and specific strategies toovercome clinical barriers (confidentiality,harm reduction vs. abstinence, psycho-pharmacology), administrative barriers(reporting and data collection) and fundingrequirements and policies. Consequently,future technical assistance depends upon thestage of change within a county.

7. During the past five years, through theleadership of SAMHSA in supportinginfrastructure development, systems trans-formation, integrated services expansion, andtechnology transfer at the state and countylevel, there has been a considerable expansionof knowledge acquired about clinicalinterventions for co-occurring disorders andalso about system change strategies forsupporting integrated services. Although thecounties appear to be aware of the literatureon integrated services and integratedprograms, they appear much less aware ofthe latest advances in system changetechnology, and methods for findinginformation on those advances.

8. The counties appear to be interested inparticipating in productive activities thatwould help them to achieve betterfunctioning systems with regard to


integrated services. Almost every participantindicated an interest in scheduling furtherpolicy academies, and many expressedinterest in more specific technicalassistance—either on site or as part of thePolicy Academy.

9. The counties appear to be very interested inreceiving more state support for their efforts;however, county representatives put lessemphasis on funding, and focused more onclearer direction from both DMH and ADPacting in concert, encouragement to initiateor continue integrated strategic planning andcollaboration, and much clearer instructionsabout how to legitimately adapt existingfunding streams or administrative practicesto support integrated treatment without fearof administrative reprisal. In addition, thecounties are requesting support in the formof technical assistance, resource and clinicalbest practice dissemination, and access totraining, but no mandates for a particularstructure or approach. This, in general,presents an opportunity for state agencies toleverage significant change by supportingcounties through a creative partnership.

RecommendationsBased on the above, the following action steps

are recommended:

1. Response from DMH and ADP. DMH andADP should issue — as soon as possible — ajoint statement to the counties through thecounty director associations thanking themfor participation and organization inproviding this information, and indicating acommitment to be responsive (even thoughthe precise response may not yet bedetermined). Responsiveness might includestatements such as referring this report tothe state Policy Academy for action, acommitment to issuing continued jointcommunications to counties, support for

future policy academies, willingness toinitiate processes to provide clearer directionin encouraging county collaboration,Proposition 63 planning, and use of existingfunding streams to support the delivery ofintegrated services. (See below) Some of theseproblem-solving strategies might be referredto the Co-occurring Disorder Committee ofCADPAAC and CMHDA to discuss with thestate Policy Academy Team.

2. Plan a follow-up Policy Academy for coun-ties. The goal of this Academy should be toprovide more detailed assistance to partici-pants, who might also benefit from a two-daysession instead of just one day. A provisioncould be made for background informationon system change technologies to supportintegrated services, adaptation of clinicalpractice advances to diverse systems, clini-cians, and clients, and specific workshops ongetting started (with a focus on organizing achange team and developing an initial con-sensus document and strategic plan) as wellas workshops on self-assessment tools forsystems and programs, quality improvementand evaluation methodology, funding andbilling strategies, policy and practice devel-opment, competency development, recordkeeping and documentation. These “con-tent” workshops would supplement time forcounty teams to meet and develop their ownplans.

3. Organize regular communication betweenthe State Policy Academy Team plus otherstate leadership and the counties,transmitted through the County DirectorAssociations and the Co-occurring DisorderWorkgroup. Communication will help theindividual counties feel less isolated, andalign state-level activities with local needsand requests.

4. Provide state-level direction and support tocounty activity. Beyond the joint responseletter mentioned in item one, state leadershipcan do a lot to stimulate and encourage


change at the county level with relativelylittle effort and resources. Examples:

a. A position statement—like the SanDiego County policy—that clarifiescurrent MediCal funding (whetherspecialty mental health, or drug, orfee-for-service) supports integratedassessment for any client to determineneeds and treatments for individualseligible for services.

b. A joint policy indicating that eachcounty system should initiate acollaborative planning process forintegrated services developmentthroughout the county, and report on itsprogress to both DMH and ADP as partof routine county reporting efforts.

c. A joint position statement thatProposition 63 planning in each countyshould meet with representatives fromalcohol and drug services to discussimproving the capacity of each systemto provide integrated services.

d. A joint commitment to seek funding fora statewide initiative that will supportsome or all counties that embark oninfrastructure development to supportintegrated services in both mental healthand alcohol and drug services, such asthe federal government funding of Co-occurring Disorder State InfrastructureGrants.

5. Introduce the availability of technicalassistance on a small scale. Counties areengaging in system change activities andseeking assistance, yet have little knowledgeof existing tools and strategies of how toadapt them to local needs. The state couldpartner with willing counties that havecreated an initial proposal to meet with thecounty planning group and assist indesigning and implementing a strategic planfor systemic development of integratedservices, and to select appropriate tools andresources. Even without state support, the

county director associations could develop aplan to make such assistance available.

6. Develop communication strategies tofacilitate information sharing betweencounties. A clear benefit exists for countiesto have access to lessons learned andstrategies developed by other counties, aswell as access to resources on co-occurringdisorder service development, programmodels, and intervention techniques. CIMHand ADP could develop a communicationsvehicle (e.g., newsletter or Web site) topromote this type of connection on a regularbasis. This vehicle also could be used toprovide access to resources, perhaps with theassistance of SAMHSA’s Co-occurringDisorder Center of Excellence (COCE).

ConclusionThe California Policy Academy for counties was

successful in creating a venue for organizing andanalyzing current county efforts to developsystemic approaches to services integration, andto create a framework in which counties couldprovide assistance to one another while offeringcollective suggestions to the state for how tosupport their efforts. This process is particularlyvaluable as California has just begun a PolicyAcademy Team at the state level, with SAMHSAsupport. A unique opportunity exists for state-county partnership in both mental health andaddictions in the creation of system change topromote integrated services in a fashion thatpreserves the value and integrity of each servicesystem while allowing for collaboration toimprove outcomes for those clients who are mostin need.

Respectfully submitted,Christie A. Cline, M.D., M.B.A., P.C.,President, Zialogic;

Kenneth Minkoff, M.D.,Senior Systems Consultant


California Institute for Mental Health2125 19th Street, 2nd Floor

Sacramento, CA 95818(916) 556-3480www.cimh.org

The California Institute for Mental Health is anon-profit public interest corporation establishedfor the purpose of promoting excellence in mentalhealth. CIMH is dedicated to a vision of “acommunity and mental health service systemwhich provides recovery and full social integrationfor persons with psychiatric disabilities; sustainsand suppor ts families and children; andpromotes mental health wellness.”

Based in Sacramento, CIMH has launchednumerous public policy projects to inform andprovide policy research and options to both policymakers and providers. CIMH also providestechnical assistance, training services, and theCathie Wright Technical Assistance Center undercontract to the California State Department ofMental Health.

Documents

California County Co-occurring Disorders Policy Academy · in the development of implementation strategies for systems, facilitated the meeting and provided content technical assistance