Achieving Dual Diagnosis Capability Across Your System of Care

Transcription

1 Achieving Dual Diagnosis Capability Across Your System of Care Steve Wiland, LMSW, ICADC Andrea Smith, CPI Manager; Carmita Williams-Brown, Data Specialist

2 As increasing attention is paid to research findings pointing to the high prevalence of co-occurring mental health and substance use disorders among those served by public sector substance use disorder treatment providers, the need for systems of care to become integrated becomes increasingly important. This session will outline a comprehensive strategy for progressing toward implementation of integration of services for Dual Disorders across the provider networks of the Detroit Wayne Mental Health Authority (DWMHA). The Dual Diagnosis Capability in Addictions Treatment framework promoted by the Substance Abuse and Mental Health Services Administration will be reviewed and the use of the DDCAT review process across DWMHA s provider network will be described. Additional resources will also be shared, that have been found useful in supporting systems to become increasingly dual diagnosis capable.

3 Learning Objectives: Participants will be able to: 1. Distinguish between Dual Diagnosis Capable and Dual Diagnosis Enhanced levels of services; 2. Understand three significant reasons why addressing cooccurring mental health disorders is important in populations receiving treatment for addictive disorders; and 3. Learn about the 35 items across the seven domains of the Dual Diagnosis Capability in Addictions Treatment assessment framework.

4 BEGINNING Unique Code F2

5 HOW DO WE KNOW IF AN ADDICTION TREATMENT PROGRAM IS DUAL-DIAGNOSIS CAPABLE?

6 Two Pre-existing Measures of Dual Diagnosis Capability COMPASS & IDDT Fidelity Scale The Comorbidity Program Audit and Self-Survey for Behavioral Health Services (COMPASS) Adult & Adolescent Program Audit Tool for Dual Diagnosis Capability Ken Minkoff & Christine Cline (2002) Designed for either mental health or addiction programs Leans in the direction of mental health program & SMI clients (Quadrant 2)

7 The Four-Quadrant model III LOW PSYCHIATRIC (psychiatrically complicated) HIGH SUBSTANCE (Dependence) HIGH PSYCHIATRIC (SPMI) HIGH SUBSTANCE (Dependence) IV LOW PSYCHIATRIC HIGH PSYCHIATRIC (mild psychopathology) (SPMI) LOW SUBSTANCE LOW SUBSTANCE I (Abuse) (Abuse) II 7

8 Two Pre-existing Measures of Dual Diagnosis Capability COMPASS & IDDT Fidelity Scale Integrated Dual Disorders Treatment (IDDT) model developed and standardized via SAMHSA for MH settings. IDDT model for persons with SMI (Quadrants 2 & 4) Mueser, Drake et al (2003) Differences between MH and Addiction Treatment: 1) Historic and cultural 2) Levels of care (physical settings) 3) Evidence-based practices 4) Role of assertive community treatment 5) Persons served (MH: Q2 & Q4; SUD: Q3 & Q4)

9 The American Society of Addiction Medicine s taxonomy system (ASAM-PPC-2R, 2001) Addiction-Only Services (AOS) Dual Diagnosis Capable (DDC) Dual Diagnosis Enhanced (DDE)

10 Addiction-Only Services (AOS) Programs that either by choice or for lack of resources, cannot accommodate clients who have psychiatric illnesses that require ongoing treatment, however stable the illness and however well-functioning the client.

11 Dual Diagnosis Capable (DDC) Programs that have a primary focus on the treatment of substance-related disorders, but are also capable of treating clients who have relatively stable diagnostic or sub-diagnostic cooccurring mental health problems related to an emotional, behavioral or cognitive disorder.

12 Dual Diagnosis Enhanced (DDE) Programs that are designed to treat clients who have more unstable or disabling co-occurring mental disorders in addition to their substancerelated disorders.

13 Rational for Developing a Dual Diagnosis Capability Index ASAM offers the road map, but no operational definitions for services; Fidelity => Adherence to an evidence-based practice model; Fidelity scales => Objective ratings of adherence; Need for objective ratings of adherence to consensus clinical guidelines or principles => Index.

14 Can we use Fidelity Scale Methodology for Objective Rating of Dual Diagnosis Capability? 3 rd -party site visit (yields data beyond self-report); Multiple sources: Review of client records, brochure & program manual; Observation of clinical process, team meeting, & supervision session; Interviews with agency director, clinicians & clients; Objective ratings on operational definitions using a 5-point scale.

15 Why do we need to measure Dual Diagnosis Capability? Generic terms like integrated care amount to feel-good rhetoric but lack specificity. Full integration (a clinician or program fully treating both mental health and substance use conditions) is sometimes presented as the only worthwhile model of integration.

16 Why do we need to measure Dual Diagnosis Capability? In reality, programs whose history and culture are much closer to substance abuse or mental health only are more likely to move towards more intermediate levels of integration (co-occurring capable). Ultimately we want and need a system with a complete range of levels of integration, from capable to enhanced.

17 LEVELS OF PROGRAM CAPACITY Fully Integrated COD Integrated * ASAM Dual Diagnosis Capable ** ASAM Dual Diagnosis Enhanced What challenges are encountered in moving toward the center? What can be done to overcome these challenges?

18 Use of the Dual Diagnosis Capability Framework and Review Instrument Reviews at least a sample of individual programs within a given region; Employs objective, third-party, direct on-site observation and review; Scores and reports on 7 domains (35 subdomain items) both separately, and aggregately.

19 Levels of Capability per DDC Framework DIMENSIONS OF CAPABILITY LEVELS OF CAPABILITY S.A./ M.H. ONLY CAPABLE ENHANCED I Program Structure Program mission, structure and financing, format for delivery of cooccurring services. II Program Milieu Physical, social and cultural environment for persons with mental health and substance use problems. III IV Clinical Process: Assessment Clinical Process: Treatment Processes for access and entry into services, screening, assessment & diagnosis. Processes for treatment including pharmacological and psychosocial evidence-based formats. V Continuity of Care Discharge and continuity for both substance use and mental health services, peer recovery supports. VI Staffing Presence, role and integration of staff with mental health and addiction expertise, supervision process. VII Training Proportion of staff trained and program s training strategy for cooccurring disorder issues.

20 Enhanced Dual Diagnosis Capability example report Scores based on DDC = Dual Diagnosis Capability in Addiction [or Mental Health] Treatment Index Capable Basic Total Score Program Structure Program Milieu Screening & Assessment Treatment Continuity Staffing Training of Care

21 SYSTEMS-LEVEL CONSIDERATIONS

22 Observations The outpatient system has moved away from addiction and mental health only status, and is moving towards co-occurring capable levels of care. The outpatient substance abuse treatment system is repositioning itself to provide services for mood and anxiety conditions. (Quadrant 3: high substance abuse + mild to moderate mental health); The outpatient mental health system is repositioning itself to provide services for mild to moderate levels of substance abuse. (Quadrant 2: high mental health + mild-tomoderate substance abuse);

23 Observations Consumers with high severity of mental health and addiction (Quadrant 4: high substance abuse high mental health) still have very few service options, however more integrated program development, as well as collaborations between substance abuse and mental health clinics, have the potential to address this significant gap.

24 The Four-Quadrant Model: Traditional loci of care Category III Severe SUD, Mild MI Locus of Care Addiction Treatment Providers Category I Mild MI, Mild SUD Locus of Care Primary Health Care Providers Category II Severe MI, Mild SUD Locus of Care Mental Health System Providers

25 Issues for consideration Its now feasible to consider that in time, a baseline of co-occurring capability is achievable across both systems. As programs who are currently in the midrange ( 2.71), move to capable status there may be further movement of those currently capable ( ), to more enhanced levels of care, although greater resources would be required to accomplish the latter.

26 Issues for consideration Programs who have undertaken a measure of their current co-occurring capability using the DDCAT or DDCMHT are in a better position to target specific areas requiring co-occurring competency building training. Programs who have undertaken a measure of their current co-occurring capability using the DDCAT or DDCMHT and then implement recommendations to increase capability can use the same tool to guide their evaluation of outcomes of changes in their capability.

27 Issues for consideration The results of each survey provides individual programs with immediate recommendations for increasing cooccurring capability. The aggregate trends that emerge from all programs surveyed across a region or state will assist decisionmakers in identifying larger issues of systemic change that could be considered for advancing dual diagnosis capability.

28 Key issues for building capability Outpatient programs vary considerably, from those that offer core components of treatment to those where treatment is driven almost entirely by individual clinician preference: One-way recovery; Cult of [practitioner] personality. In the case of the latter it has proved far more difficult to implement programmatic change.

29 Key issues for building capability The implementation of recommended co-occurring evidence-based practices at a programmatic level is consistent with a system that is moving from addiction-only to dual-diagnosis capable For many programs, the next step in capability building will be to increase either the mental health or the substance abuse content of their existing treatment regimes rather than the implementation of a specific COD evidence-based practice.

30 THE EXPERIENCE OF THE DETROIT WAYNE MENTAL HEALTH AUTHORITY

31 DWMHA Developmental History IDDT Team Development; SUD Coordinating Agency-contracted requirement to engage in an annual DDCAT review; Audit vs. Performance Improvement opportunity; Technical Assistance, coaching; Financial incentive leading to best-foot-forward and subsequent grade inflation; Once the approach was clearly changed to one of performance-improvement, grade-inflation pressures decreased, and scores dipped to some extent before resuming an upward trend.

32 DWMHA Developmental History MDCH/MDHHS MIFAST resources; Systems Transformation Block Grant projects; Sustainability planning & resourcing:

33

34

35

36 DWMHA Recent Progress to Date The chart lists the DDCAT & DDMHT Site Reviews completed by DWMHA (FY15) to date (as of ). Three agencies scored in the AOS/DDC (2-2.99) ranking. The other agencies scored at a DDC to DDC/DDE ranking. Addiction-Only Services [AOS] = (1 1.99) Addiction-Only/Dual Diagnosis Capable [AOS/DDC] = (2 2.99) Dual Diagnosis Capable [DDC] = (3 3.49) Dual Diagnosis Capable/Dual Diagnosis Enhanced [DDC/DDE] = ( ) Dual Diagnosis Enhanced [DDE] = ( )

37 DWMHA 2014/2015 DDCAT & DDMHT Site Review Score 3rd Quarter Star Center 2.82 Oakdale Heigra Recovery 4.01 Adult Well Being Community Care Services Positive Images Name of Agency Operation Get Down Sobriety House New Center Mental Health Arab American Chaldean Council- Warren 3.51 Arab American Chaldean Council-7 mile 3.72 Metro East 2.82 Black Family Development 3.12 The Guidance Center Professional Psychological & Psychatric Services III Jabez Recovery Management Services Northeast Guidance Center Dual Diagnosis Capability Scores

38 DWMHA 2015 DDC Area I Area II Area III Area IV Area V Area VI Area VII Northeast Guidance Center Jabez Recovery Management Services Professional Psychological & Psychatric Services III The Guidance Center Black Family Development Metro East Arab American Chaldean Council- 7 mile Arab American Chaldean Council- Warren New Center Mental Health Sobriety House Operation Get Down Positive Images Community Care Services Adult Well Being Oakdale Heigra Recovery Star Center AVERAGE SCORES:

39 AREA IV Clinical Process: Treatment A. Integrated Treatment Plans [64.67%] B. Monitoring of Disorder Interaction [58.67%] C. Protocols for Active Use / Relapse [64%] D. Stage-wise Treatment Interventions [54.67%] E. Pharmacological Support for Addictions Treatment [65.33%] F. Specialized Psychosocial Interventions [59.33%] G. Integrated Client Education [58.33%] H. Family Education/Support [45.33%] I. Peer-led Support Group Resources [53.33%] J. Other Peer Recovery Support Services [53.33%]

40 AREA IV Clinical Process: Treatment RANKED AREAS of NEED 1. Family Education/Support [45.33%] 2. Peer-led Support Group Resources [53.33%] 3. Other Peer Recovery Support Services [53.33%] 4. Stage-wise Treatment Interventions [54.67%] 5. Integrated Client Education [58.33%] 6. Monitoring of Disorder Interaction [58.67%] 7. Specialized Psychosocial Interventions [59.33%] 8. Protocols for Active Use / Relapse [64%] 9. Integrated Treatment Plans [64.67%] 10. Pharmacological Support for Addictions Treatment [65.33%]

41 Training Resources / Opportunities Multiple public-domain resources posted or linked at:

42 Family Education / Support: 20 educational slidesets

43 Family Education / Support: Educational slideset examples

44 Peer-led Support Group Resources

45 Peer-led Support Group Resources

46 Stage-wise Treatment Interventions

47 Other Training Resources / Opportunities Motivational Interviewing series of 20 online learning modules (~30-40 min. each)

48

49 AREA V Continuity of Care A. Integrated Discharge Planning [52%] B. Treatment Continuity Capacity [52%] C. Integrated Ongoing Recovery Focus [66.67%] D. Community-based Peer Support Groups [60%] E. Ongoing Pharmacological Support [52%]

50 AREA V Continuity of Care RANKED AREAS OF NEED 1. Ongoing Pharmacological Support [52%] 2. Integrated Discharge Planning [52%] 3. Treatment Continuity Capacity [52%] 4. Community-based Peer Support Groups [60%] 5. Integrated Ongoing Recovery Focus [66.67%]

51 Ongoing Pharmacological Support

52 Training Opportunities in development Online learning modules Overview of Co-occurring Disorders Engagement & Understanding Difficult Behavior Stages of Change and Treatment Motivational Enhancement I & II Others Integrated Discharge Planning Treatment Continuity

53 Comments, Questions? ENDING Unique Code 2L