State Initiatives on Dual Disorders

1. State Initiatives on Dual Disorders Presented by Lenore A. Kola, Ph.D., Co-Director Patrick E. Boyle, MSSA, LISW, LICDC Director of Clinical Training And Barbara Wieder, PhD Director, Evidence Based Practice Implementation Project the Ohio SAMI CCOE is a partnership between the Mandel School of Applied Social Sciences and the Dept of Psychiatry, CASE School of Medicine, Case Western Reserve University in collaboration with the Ohio Departments of Mental Health and Alcohol and Drug Addiction Services May 6, 2005

2. Treatment Strategies Clinical Practice and the Community As we strengthen our knowledge on treatment of dual disorders and supported employment, it becomes increasingly urgent to expand our research on evidence based practice on to strategies to optimize their translation into clinical practice and the community State Initiatives on Dual Disorders

3. Bridging the Gap Between Research and Practice • Assuring that technology transfer actually occurs – using evidence based treatment models such as the Integrated Dual Disorder Treatment Model and Supported Employment Model • Using more effective dissemination and training strategies • Involve community treatment providers in both practice and research State Initiatives on Dual Disorders

4. Introduction • People with serious mental illness can recover and work • People are much more likely to recover if they have access to IDDT • People are much more likely to work if they have access to Supported Employment • Implementation requires thoughtful planning and sustained efforts State Initiatives on Dual Disorders

5. Integrated Dual Disorders Treatment - IDDT: What is it? • The New Hampshire-Dartmouth Model • Robert Drake, MD and colleagues • Treatment of substance use disorder and mental illness together • Same team • Same location • Same time (MI and SA together) State Initiatives on Dual Disorders

6. Ten Treatment Principlesof IDDT 1. Integration of substance abuse & mental health treatments • Same providers within program or agency • Team based services • Excellent communication • Source: Mercer-McFadden, C., Drake, R.E., Clark, R.E., Verven, N., Noordsy, D.L., Fox, T.S. (1998). Substance Abuse Treatment for people with Severe Mental Disorders: a program manager’s guide. New Hampshire-Dartmouth Psychiatric Research Center. State Initiatives on Dual Disorders

7. Ten Treatment Principlesof IDDT 2. Flexibility & specialization of clinicians • Specialties: substance abuse, employment, housing/residential, medical • Cross-trained staff 3. Assertive outreach • Community based • Engage and monitor State Initiatives on Dual Disorders

8. Ten Treatment Principlesof IDDT 4. Recognition of client preferences • Client-centered goals • Cultural competence 5. Close Monitoring • Medication & response to treatment State Initiatives on Dual Disorders

9. Ten Treatment Principlesof IDDT 6. Comprehensive Services • Intensive Case Management (ICM or ACT teams) • Supported Employment • Family Psychoeducation • Illness Management & Recovery • Residential 7. Range of Stable Living Situations • Wet, damp, and dry & supported • Necessary for recovery • Housing First State Initiatives on Dual Disorders

10. Ten Treatment Principlesof IDDT 8. The Long-term Perspective • No arbitrary time limits 9. Stage-wise Treatment • Assessed and staged regularly • Interventions focused on stage of readiness for change • Engagement, Persuasion, Active, Relapse Prevention 10. Optimism • Provider characteristic for selection • Celebrate successes State Initiatives on Dual Disorders

11. The “Cost” of Not Integrating Treatment • Demoralization of treatment professionals - staff attraction, retention, and turnover • Decay of treatment systems • Lack of public support for treatment • Ignoring: • Personal goals of people we serve • Potential of people we serve • Opportunities for their productive participation in community life State Initiatives on Dual Disorders

12. IDDT improves abstinence outcomes State Initiatives on Dual Disorders

13. Why Focus on Employment? • Viewed by many as an essential part of recovery • Most consumers want to work • A typical role for adults in our society State Initiatives on Dual Disorders

14. Work Is Treatment • Reduces symptoms of depression. • Provides reasons to comply with other treatment goals. • Experience fewer hospitalizations. • Many feel better about themselves (improved self-esteem). State Initiatives on Dual Disorders

15. Benefits of Competitive Employment: Research Evidence • Increased income • Change in self-identity • Increased quality of life • Reduced symptoms Sources: Arns, 1993, 1995; Bond, 2001; Fabian, 1989, 1992; Mueser, 1997; Van Dongen, 1996, 1998 State Initiatives on Dual Disorders

16. Competitive Employment for People with Severe Mental Illness - The Gap • Say they want to work: 60%-70% • Are currently working: <15% State Initiatives on Dual Disorders

17. Evidence-Based Principles for SE • Eligibility is based on consumer choice • Integrated with mental health • Competitive employment is the goal • Rapid job search • Consumer preferences are important • Time-unlimited Follow Along • Personalized benefit planning State Initiatives on Dual Disorders

18. 1. Eligibility Is Based on Consumer Choice Consumers are not excluded because they are not “ready” or because of: prior work history, diagnosis, gender, hospitalization history, substance use, symptoms, or other characteristics State Initiatives on Dual Disorders

19. Integrated with Mental Health Treatment • Employment specialists meet frequently with the mental health treatment team State Initiatives on Dual Disorders

20. 3. Competitive Employment Is the Goal Competitive jobs: • Pay at least minimum wage • Are jobs that could be filled by people who do, or do not have disabilities • Are hired by the employer State Initiatives on Dual Disorders

21. 4. Rapid Job Search Is Used The service agency avoids: • Lengthy pre-employment assessment, counseling, work adjustment or training • Volunteer jobs are not promoted as a means to prepare for work State Initiatives on Dual Disorders

22. Consumer Preferences are Important • Job finding is based on consumers’ preferences, strengths, and work experiences, not on a pool of jobs that are available State Initiatives on Dual Disorders

23. Follow-Along Supports Are Time-Unlimited • Supported employment staff continue to stay in regular contact with consumer and/or employer without arbitrary time limits State Initiatives on Dual Disorders

24. 7. Personalized Benefits Planning • Access to good information about earned income and the effect on benefits increases the likelihood that consumers will return to work State Initiatives on Dual Disorders

25. Implementation Plan for Agencies Phases: • Enabling/Motivating • Implementation • Sustaining State Initiatives on Dual Disorders

26. Implementation Plan for Agencies • Enabling/Motivation Phase • Consensus Building • Information sharing • Ongoing discussions • Steering Committees • Baseline Measures State Initiatives on Dual Disorders

27. Implementation Plan for Agencies • Implementation Phase • Steering Committee • Determines priorities & action plan • Kickoffs! • Training • for the entire treatment team State Initiatives on Dual Disorders

28. Implementation Plan • Sustaining Phase • Implementation Monitoring • Ongoing Consultation (team/leader) • Fidelity Measure – Feedback – Steering Committee – Service Improvements • Learning & Dissemination State Initiatives on Dual Disorders

29. Champions are vital Team leaders and other self-identified champions --share their enthusiasm --use the model as a roadmap --talk to team members about ways to implement the model State Initiatives on Dual Disorders

30. Good Implementation Doesn’t Happen Overnight • Changing the way we do things is hard! • Thinking – Practices - Policies • Important to be respectful that people need time to change State Initiatives on Dual Disorders

31. Project Goals • Improve the rates of recovery (as indicated by the evidence based practices) • Nurture services toward high fidelity • Monitor the implementation process and outcomes! • Evaluate • Learn State Initiatives on Dual Disorders

32. Nurture toward high fidelity • Produce better outcomes • Monitors progress toward adherence • Results provide direction for “next steps” to improve services • Useful tool to help staff and technical assistance consultant/trainer collaborate on strategies State Initiatives on Dual Disorders

33. Measuring Fidelity to the IDDT and SE Models • Treatment Fidelity Scales • Subscale I. Organizational Characteristics • 12 components • Subscale II. Treatment Characteristics • 14 components – IDDT • 15 components – SE State Initiatives on Dual Disorders

34. Part I: Organizational Characteristics • Items • 01: Program Philosophy • 02: Eligibility/Client Identification • 03: Penetration • 04: Assessment • 05: Treatment Plan • 06: Treatment State Initiatives on Dual Disorders

35. Part I: Organizational Characteristics • Items • 07: Training • 08: Supervision • 09: Process Monitoring • 010: Outcome Monitoring • 011: Quality Improvement • 012: Client Choice State Initiatives on Dual Disorders

36. Measuring Fidelity to the Model • Independent raters visit a program • Interview direct service providers, administrators, consumers, and family members • Review charts and other documents • Rate each component on a 1-5 scale • CCOE provides a qualitative and quantitative report with recommendations State Initiatives on Dual Disorders

37. Measuring Fidelity to the Model • Scoring ranges • 1 = no evidence of implementation • 2 = serious departure from full implementation • 3 = moderate departure from full implementation • 4 = moderate implementation • 5 = full implementation State Initiatives on Dual Disorders

38. Monitoring the implementation process • Many factors influence the course • Each agency and community brings a unique set of characteristics • Observing the process helps understand important factors • Analyzing observations for useful strategies • Measure against outcomes State Initiatives on Dual Disorders

39. Add to the knowledge base • What does it take to prepare for, develop, and sustain a high quality practices? • What are the major facilitators and challenges involved in implementation? • Lessons learned will inform others • Revised training and consulting tools will be developed from project data BW State Initiatives on Dual Disorders

40. In Summary • People with serious mental illness can recover and work • People are much more likely to recover if they have access to IDDT • People are much more likely to work if they have access to Supported Employment • Implementation requires thoughtful planning and sustained efforts State Initiatives on Dual Disorders