DRAFT: Implementing CoOccurring Disorder Services in Iowa

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DRAFT Implementing Co-Occurring Disorder
Services in Iowa

• Allen Parks, EdD, MPH Director/Administrator
• Division of Mental Health and Disability Services
• Iowa Department of Human Services
• Summer 2007
• www.aparks_at_dhs.state.ia.us

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Cost of Substance Use

• Estimated cost of medical treatment for substance
  use and its related medical illnesses is 11.9
  billion
• Estimated cost to society for substance use is
  294.3 billion

3
Criminal Justice System Referrals for Substance
Abuse Treatment

• In 2002, criminal justice referrals accounted for
  655,000 substance abuse treatment admissions in
  the civilian delivery system.
• This was an estimated 36 percent of the 1.9
  million admissions in the federal Treatment
  Episode Data Set (TEDS).
• Between 1992 and 2002, criminal justice referrals
  increased by 32, exceeding the 23 increase in
  total admissions over the same time period.

The DASIS Report 7/30/04
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Actual Causes of Death in the US in 1990
Source McGinnis JM, Foege WH (1993). Actual
causes of death in the United States. JAMA
(270) 18, 2207-2212
.
5
Selected Conditions Attributable to Substance
Abuse
Source Jeffrey Merrill, CASA Substance Abuse
Epidemiologic Database, 1993
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Receiving Specialty Treatment

• Of the 3.5 million people who received treatment
  for substance use disorders in 2002, 2.3 million
  received treatment in specialty facilities
• Inpatient or Outpatient Alcohol or drug
  rehabilitation facilities
• Hospitals (inpatient only)
• Mental Health Centers

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Most People Who Needed Treatment for an Illicit
Drug Problem and Who Did Not Receive Treatment
Did Not Feel A Need for Treatment
Female
Male
Felt a need for treatment
Felt no need for treatment
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Child Neglect
Depression
Crime
The demand for illicit drugs is associated with
the denial of impact and a failure to recognize
the association between illicit drug consumption
and these problems.
Anxiety
Trauma
Child Abuse
The perpetuation of substance use disorders is
facilitated by the denial of the impact of the
problems associated with those disorders and by
the powerful reinforcing properties of substances
of abuse which produce those disorders.
DOMESTIC VIOLENCE
Homelessness
Psychosis
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Dual Disorder Problems

• About 50 70 of individuals with severe mental
  disorders are affected by substance abuse.
• Dual diagnosis is associated with a variety of
  negative outcomes including
• Higher rates of relapse
• Hospitalization
• Violence
• Incarceration
• Homelessness
• Serious infections (Hepatitis, HIV)

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Scope of the Problem

• Substance abuse is the most common and
  clinically significant comorbid disorder among
  adults with severe mental illness.
• Drake RE, Essock SM, Shaner A, Carey KB, Minkoff
  K, Kola L, Lynde D, Osher F, Clark R, and
  Rickards L Implementing Dual Diagnosis for
  Clients with Severe Mental Illness. Psychiatric
  Services, April 2001,Vol. 52, No. 4, 469.

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Competition among other human service systems
(mental health, development disabilities)
Provision of Substance Abuse Services
Workforce confronting increasingly complex
clinical pictures
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Silos

• The parallel but separate mental health and
  substance abuse treatment systems so common in
  the US deliver fragmented and ineffective care.

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Integrated Systems of Care

N

E

V

T

I

E


R

O


Recovery Management

P

N

Clinical Treatment Services


Outreach and Engagement

Screening

Detoxification

Crisis Intervention

Brief Intervention
Assessment

Treatment Planning

Case Management

Education

Evidence
-
based Treatment Practices

Pharmacotherapies

Mental Health Services

Medication Monitoring


Relapse Prevention

Primary Health
Care

Continuing Care




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Comprehensive, Continuous, Integrated System of
Care - CCI SoC (TIP42)

• A model to bring the mental health and substance
  abuse treatment systems (and other systems) into
  an integrated planning process to develop a
  comprehensive, integrated system of care. Based
  on
• Awareness that COD are the expectation throughout
  the service system.
• The entire system is organized in ways consistent
  with this assumption.
• There are system-level policies and financing
  (driven by SAMHSA work by Minkoff, 2001).

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CCI SoC Assumptions (TIP42)

• The four-quadrant model is a valid model for
  service planning.
• Individuals with COD benefit from continuous,
  integrated treatment relationships.
• Programs should provide integrated primary
  treatment for substance use and mental disorders
  in which interventions are matched to
• Diagnosis
• Phase of Recovery
• State of change
• Level of functioning
• Level of care
• Presence of external supports and/or
  contingencies.

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Transformation Values
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Consumer/Family Driven
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Underlying Expectations
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Interventions (TIP42)

• The specific treatment strategies, therapies, or
  techniques that are used to treat one or more
  disorders. Interventions may include, but are
  not limited to
• Individual or group counseling
• Psychopharmacology
• Cognitive-behavioral therapy
• Motivational enhancement
• Family intervention
• 12-step Recovery meeting
• Case management
• Skills training
• Other

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Integrated Interventions (TIP42)

• Are specific treatment strategies or therapeutic
  techniques in which interventions for both
  disorders are combined in a single session or
  interaction, or in a series of interactions or
  multiple sessions. Some examples include
• Integrated screening and assessment process.
• Dual recovery mutual self-help meetings.
• Dual recovery groups in which recovery skills for
  both disorders are discussed.
• Motivational enhancement interventions that
  address issues related to both mental health and
  substance abuse problems.
• Group interventions for persons with multiple
  disorders.
• Combined psychopharmacological interventions, in
  which an individual receives medication designed
  to reduce cravings for substances as well as
  medication for a mental disorder.

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Guiding Principles in Treating Clients with COD
(TIP42)

• Employ a recovery perspective
• Adopt a multi-problem view
• Develop a phased approach to treatment
• Address specific real-life problems early in
  treatment
• Plan for clients cognitive and functional
  impairments
• Use support systems to maintain and extend
  treatment effectiveness

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Treatment Relationship
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Balancing
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Integrated Treatment (TIP42)

• Any mechanism by which treatment interventions
  for COD are combined within the context of a
  primary treatment relationship or service
  settingan active combination of interventions
  intended to address substance use and mental
  disorders in order to treat both disorders,
  related to problems, and the whole person more
  effectively.

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Integrated Treatment
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Integration

• Dual diagnosis treatments combine or integrate
  mental health and substance abuse interventions
  at all levels and the same level of clinical
  interaction.
• Integration also involves modifying traditional
  interventions (i.e., social skills training,
  counseling, family interventions).

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Recovery Model
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Support and Manage Recovery

• Reduce treatment system gaps
• Facilitate and support community efforts to build
  the capacity to participate in the public
  dialogue about addiction and recovery
• Promote access to treatment for those abusing or
  dependent on prescription drugs
• Define and support recovery management services

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Major Components of the Co-occurring Policy
Academy

• Screening
• Practitioner credentialing/licensing
• Comprehensive assessment
• Evidence- and consensus based services
• Reimbursement
• Maximize funding sources
• Eliminate disparities
• Develop marketing plan
• Adapt existing information systems

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Strategy 1 Screening

• Establish screening work group.
• Present recommendations for adolescent and adult
  screening tools.
• Implement screening with IME.
• Implement screening with CMHCs.
• Initiate administrative rules to support
  screening processes.
• Update

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Strategy 2 Practitioner and Provider Standards
and Competencies

• Establish core competencies for all COD
  providers.
• Consult with Annapolis Coalition on competency
  development.
• Establish licensing and accreditation standards
  for COD providers.
• Develop integrated licensing and accreditation
  for MH and SA providers.
• Utilize MHDS Training Institute for Training
• Update

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Strategy 3 Comprehensive Assessments

• Establish assessment work group to identify
  adolescent and adult assessment domains.
• Integrate assessment requirements with IME, CMHCs
  and other providers.
• Initiate administrative rules for implementation.
• Update

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Strategy 4 Promote EBP- and consensus-based
service models

• Disseminate SAMHSA info, TIPs (TIP 42) and other
  information on EBPs
• Review and disseminate other EBPs across service
  delivery system
• Integrate Annapolis Coalition competency approach
  with MHDS TI
• Implement best training practices and self study
  programs
• Identify potential SAMHSA/COCE support for
  training programs.
• Implement training program
• Develop funding to support use of EBPs with IME
• Develop PCP training program on COD
• Review regulatory contract standards to include
  requirements for the use of EBPs
• Provide TA for providers through MHDS TI
• Update

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Strategy 5 Assure appropriate reimbursement for
COD

• Review pricing strategies
• Engage IME and third party payors on strategy for
  developing and/or enhancing COD rates
• Implement funding strategy
• Update

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Strategy 6 Maximize local, state, and federal
funding

• Request TA from SAMHSA on funding approaches
• Identify funding sources and seek out assistance.
• Increase availability of juvenile drug and mental
  health courts to support community based COD.
• Implement anti-stigma and public education
  campaign
• Develop action plans with Juvenile Justice and
  Department of Corrections for COD services.
• Update

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Strategy 7Improve Access and Eliminate
Disparities

• Identify sources of disparities and develop
  strategies to overcome barriers
• Identify geoaccess characteristics of provider
  delivery system related to COD.
• Apply for Co-Sig grant
• Update

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Strategy 8 Develop COD Marketing Plan

• Develop and implement public education program on
  COD
• Develop white papers for Governor and
  Legislature.
• Develop consumer and family education resources.
• Develop healthcare provider information
  materials.
• Update

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Strategy 9 Enhance IS Capacity

• Develop interagency linkage plan.
• Develop capacity to share data in one warehouse.
• Integrate datasets across DHS, IDPH, DOC, IME,
  CMHCs, MH, and SA providers.
• Update

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12 Steps for CCISC Implementation

• Integrated system planning process.
• Formal consensus on CCISC model.
• Formal consensus on funding the CCISC model.
• Identification of priority populations.
• Development and implementation of program
  standards.
• Structures for intersystem and inter-program care
  coordination.
• Development and implementation of practice
  guidelines.
• Facilitation of identification, welcoming and
  accessibility
• Implementation of continuous integrated
  treatment.
• Development of basic dual diagnosis capable
  competencies for all clinicians.
• Implementation of a system wide training plan.
• Development of a plan for comprehensive program
  array.
• Minkoff Cline

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Other key CCISC components

• Evidence-based and best practices
• Peer dual recovery supports
• Residential supports and services
• Continuum of levels of care
• Intensive outpatient
• Day treatment
• Residential treatment
• Hospitalization
• Minkoff Cline

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Critical Components

• Welcoming Vision
• Staged interventions
• Assertive outreach
• Motivational interventions
• Counseling
• Social support interventions

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Issues/Recommendations

• Ongoing collaboration between IDHS and IDPH (and
  others)at all levels.
• Need to drive a system vision through all
  activities during system transformation.
• Key components of the system lack clarity in
  terms of roles, populations, locations served
  (I.e., CMHCs, ESPs).
• Need to clarify that COD is the major EBP for
  several years.
• There are inadequate infrastructures to train the
  system workforce to improve the quality of care
  and specific areas such as CQI, EBP and Outcomes,
  and monitor system performance through IS.

• Update system vision statement through CODPA and
  all agencies.
• Redesign COD to implement a comprehensive,
  integrate system of care checking activities
  against vision statement.
• Continue to support agency and provider-level
  CQI, EBP, and Outcomes practice.
• Utilize various systems change tools.
• Develop and Implement Collaborative Behavioral
  Health Workforce Competency Training Plan
  (legislative mandate).
• Continue to fund and develop adequate IS capacity
  that supports system transformation.

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Recommendations II

• Implement training through MHDSTI
• Utilize various tools to look at Systems
  Competency, Program Competence, and Clinician
  Competence
• Develop Performance measures and Outcome
  Indicators
• Target pilot rollout providers/organizations

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CCI SoC States/Projects (TIP42)

• Alabama
• Alaska
• Arizona
• District of Columbia
• Florida
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Montana
• New Mexico
• Oregon
• Texas
• Virginia

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No discussion of substance use disorders should
occur without recognizing the psychological,
physiological, and social effects of Drugs of
Abuse. Effective Prevention and Treatment
Strategies must discourage drug use, not
rationalize or apologize for their consumption.