DRAFT : Implementing Co-Occurring Disorder Services in Iowa

1. 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@dhs.state.ia.us

2. 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

4. 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

6. 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

7. 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

8. 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

9. 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)

10. 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.

11. Limited Dollars Reduced State Budgets Competition among other human service systems (mental health, development disabilities) Provision of Substance Abuse Services Workforce confronting increasingly complex clinical pictures

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

13. Integrated Systems of Care E N 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 Mental Health Services Pharmacotherapies Medication Monitoring Relapse Prevention Primary Health Care Continuing Care

14. 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).

15. 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.

16. Transformation Values

17. Consumer/Family Driven

18. Underlying Expectations

19. 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

20. 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.

21. 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 client’s cognitive and functional impairments • Use support systems to maintain and extend treatment effectiveness

22. Treatment Relationship

23. Balancing

24. Integrated Treatment (TIP42) • Any mechanism by which treatment interventions for COD are combined within the context of a primary treatment relationship or service setting…an 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.

25. Integrated Treatment

26. 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).

27. Recovery Model

28. 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

29. 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

30. 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:

31. 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:

32. 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:

33. 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:

34. 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:

35. 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:

36. Strategy 7:Improve 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:

37. 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:

38. 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:

39. 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

40. 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

41. Critical Components • Welcoming Vision • Staged interventions • Assertive outreach • Motivational interventions • Counseling • Social support interventions

42. 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. Issues/Recommendations

43. 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

45. CCI SoC States/Projects (TIP42) • Alabama • Alaska • Arizona • District of Columbia • Florida • Louisiana • Maine • Maryland • Massachusetts • Michigan • Montana • New Mexico • Oregon • Texas • Virginia

46. 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.