Co-Occurring Mental Health and Substance Use Disorder Treatment Coordination Models

Prepared for Department of Health Care Services Annual Substance Use Disorder Conference August 22, 2019

California Health Policy Strategies, LLC

California Health Policy Strategies, LLC

Our Partners

Fresno County Division of Behavioral Health Services and

Turning Point of Central California, Inc

San Mateo Division of Behavioral Health Services and

Our Common Ground, Inc

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Why Focus on Co-Occurring Disorders?

• Co-occurring disorders are common in the community and even more so in treatment settings

• Co-occurring disorders lead to worse outcomes and higher costs than single disorders

• Evidence-based models exist and can be implemented• Providers and consumers want a better system and

services• Few than 10% of people get the treatments they need.

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Six Guiding Principles in Treating Clients With COD from Treatment Improvement Protocol 42 1. Employ a recovery perspective2. Adopt a multi-problem viewpoint3. Develop a phased approach to treatment4. Address specific real-life problems early in

treatment5. Plan for the client’s cognitive and functional

impairments6. Use support systems to maintain and extend

treatment effectiveness. 3

CO-OCCURRING DISORDERS IN TREATMENT SETTINGS

Community sample prevalence rates are high, but Co-morbidity rates in treatment-seeking populations are even higher (2-3x higher)

The highest rates are found in institutional populations — inpatient and outpatient psychiatric units, addiction treatment programs and jails 1, 2, 3, 4

1.Hien D et al. Psychiatr Serv. 1997(Aug);48(8):1058-1063; 2. Jordan LC et al. J Ment Health Adm. 1996(Summer);23(3):260-271; 3. Kokkevi A et al. Compr Psychiatry. 1995(Sept-Oct);36(5):329-337; 4. Regier DA et al. JAMA. 1990(Nov 21);264(19):2511-2518

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Four basic findings related to mental health & substance use disorders: • Co-occurrence of mental health and substance use

disorders is common, ranging from mild to severe conditions

• Dual and multiple diagnoses are associated with very costly negative outcomes, including higher rates of relapse, hospitalizations, incarceration, homelessness, violence, and serious infections

• The parallel but separate mental health and substance abuse treatment systems deliver fragmented and ineffective care

• Treatments aimed at addressing both disorders at the same time are generally more effective than dealing with one disorder at a time.

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Definitions

Co-Occurring Disorders: co-existing mental health and substance use disorders which are intertwined and interactional. Also known as Dual-Diagnosed.

Care Coordination: deliberately organizing patient care activities and sharing information amongst practitioners involved in a patient’s care.

Integrated Care: treatment for mental health and SUD simultaneously, in the same location, by a team of practitioners who address all issues. One team, one treatment plan, one philosophical treatment approach.

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Current Approaches to Delivering Coordinated Co-Occurring Services • Dual licenses, certifications, and contracts for

specialty services • Embedding specialty service staff in SUD programs

or AOD certified counselors in MH programs• Co-location of specialty services • Coordination of services among multiple agencies • Formal or informal partnerships with housing

agencies required by CJ contracts (CDCR/AB109)• Housing grants with mental health intensive case

management or outpatient services• Whole person care case management

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Why Do We Need to Measure Co-Occurring Capability?• Generic terms “integrated” or “enhanced” are “feel• good” rhetoric but lack specificity• Systems and providers seek guidance, objective

criteria and benchmarks for providing the best possible services to achieve best outcomes

• Patients and families should be informed about the range of services, to express preferences and make educated treatment decisions

• Change efforts can be focused and outcomes of these• initiatives assessed and improved

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Dual Diagnosis Capability in Addiction Treatment Index, Version 4.0 (SAMHSA 2011)

• Practical program level policy, practice and workforce benchmarks based on scientific literature and expert consensus

• Developed in 2002 in response to the need for standards

• Observational methodology includes interviews; document review; social, environmental & cultural ethnography (vs. self-report)

• Iterative process of measure refinement: field testing and psychometric analyses

• Materials include the index, manual, toolkit & workbook for scoring

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DDCAT FRAMEWORK – 35 item rating tool organized into 7 dimensions

• Policy Dimensions • Program Structure, Program Milieu

• Clinical Practice Dimensions • Assessment, Treatment, Continuity of Care

• Workforce Dimensions • Staffing, Training

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ASAM TAXONOMY OF DUAL DIAGNOSIS SERVICES (ASAM, 2001)

• Addition Only Services(AOS) - serve clients with no or minimal co- occurring disorders. May attempt to engage individuals with mild to moderate mental health disorders without specialized interventions.

• Dual Diagnosis Capable (DDC) -serve clients with low severity mental health disorders that are relatively stable and accommodate and address COD to some extent in policies, procedures assessment and programming.

• Dual Diagnosis Enhanced (DDE) – accommodate and serve clients with more severe, unstable mental health disorders with fully developed structure to support treatment of both conditions.

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Program Structure

• Primary treatment focus as stated in mission statement

• Organizational certification and licensure• Coordination and collaboration with mental health

services• Ability to merge funding streams to provide COD

services• Engagement and welcome of clients with COD• Display and distribution of substance abuse and

mental health related literature and patient educational materials

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Clinical Practice – Assessment

• Routine screening for mental health issues • Routine assessment for clients who screen positive• Frequency and documentation of diagnoses• Documentation of history in the medical record• Capability to provide services based on clients’

acuity of symptoms• Capability to provide services based on severity

and persistence of disability• Initial assessment of readiness for change

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Clinical Practice – Treatment

• Documentation in treatment plans• Ongoing capability to assess and monitor disorders• Emergencies and crisis management • Ongoing assessment of readiness for change• Medication evaluation, management, monitoring • Specialized interventions, psychoeducation • Family education and support• Use of self-help groups and peer recovery support

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Clinical Practice – Continuity of Care

• Discharge planning addressing all needs• Capacity to maintain treatment continuity• Focus on ongoing recovery• Documented facilitation to self-help groups• Documentation of sufficient supply and

compliance plan for medication

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Workforce Dimensions

• Access to services from a psychiatrist or other prescriber

• On site staff with certification or licensure Access to supervision or consultation

• Supervision, case management, or utilization review procedures for COD

• Peer/Alumni supports• All staff have basic training• Clinical staff members have advanced

specialized training

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Summary

• DDCAT is a psychometrically valid measure of co-occurring capability for addiction programs

• Best when used by outside raters, but possible to conduct fairly accurate self-rating

• Leads directly to implementation plan and toolkit provides examples of strategies to increase capability

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California Health Policy Strategies, LLC

Vision of Integrated Treatment: One program provides treatment for both disorders

Mental and substance use disorders are treated by the same clinicians

The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders

Treatment is characterized by a slow pace and a long-term perspective

Providers offer motivational counseling 12-Step groups are available to those who choose to participate Pharmacotherapies are utilized according to consumers

psychiatric and other medical needs Trauma-informed approaches and sensitivity are utilized

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California Health Policy Strategies, LLC

Resources

Dual Diagnosis Capability in Addiction Treatment https://www.centerforebp.case.edu/client-files/pdf/ddcattoolkit.pdf

Substance Abuse Treatment for Persons with Co-Occurring Disorders TIP 42 https://store.samhsa.gov/system/files/sma13-3992.pdf

Integrated Treatment For Co-Occurring Disorders https://www.integration.samhsa.gov/integrated-care-models/Co_Occ_Disorders_04.pdf

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California Health Policy Strategies, LLC

For Further Information:

This Case Study was prepared by California Health Policy Strategies (CalHPS)for the California Health Care Foundation

For more information about CalHPS, please visit www.calhps.com.

Questions contact: Elizabeth Stanley-Salazar MPHsalazar.stanley@gmail.com

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