Stanley Sacks, PHD, CIRP, NDRI, New York, NY
Michael Chaple, PHD, CIRP, NDRI, New York, NY
ChackuMathai, CPRP, NYAPRS, Albany, NY
presentation to — NYAPRS 29th Annual Conference,
“Bringing Recovery Home for All,”
September 14-16, 2011, Hudson Valley Resort and Conference Center, Kerhonkson, NY
1
What is CEIC’s purpose?
Fosters the implementation
of
integrated care in screening,
assessment, and evidence-based
interventions
for New York State (NYS) residents with
co-occurring conditions
and facilitates OMH and OASAS initiatives
in this area
2
Timeline
May, 2007
December, 2007
June 20 & July 31, 2008
November 1, 2008
New York State (NYS) Office of Alcoholism & Substance
Abuse Services (OASAS) and Office of Mental Health
(OMH) convene a Co-occurring Disorders (COD) Task
Force (2007)
The NYS COD Task force makes recommendations
The Directors of licensed substance abuse and mental
health programs receive two letters with
recommendations for integrating services for COD from
the Commissioners of OASAS and OMH
The New York State Health Foundation (NYSHealth)
funds the Center for Excellence in Integrated Care
(CEIC, pronounced “seek”)
3
What does CEIC do?
Provides technical assistance
(hands-on, intensive, and longitudinal)

Engages Leadership

Performs on-site assessments

Presents site reports

Conducts provider forums

Builds collaborations and informal networks

Holds Peer Recovery Workshops


Supplies ongoing support, guidance,
and consultation
Links programs to resources, such as FIT, TIP 42, and related inservice training, as well as other trainings and curricula
4
CEIC Assessment Methods
 Uses DDCA[MH]T
(Dual Disorder Capability in Addiction Treatment
and Dual Disorder Capability in Mental Health Treatment)
 Samples individual clinics within regions
 Employs direct onsite observation
 Scores and reports on 7 domains and overall
 Makes specific recommendations to raise
capability
5
Improving Co-occurring Capability
Recommendations by DDCA[MH]T Dimensions
Dimensions of
Capability
Levels of Capability
SA/MH only
Capable
Enhanced
I
Program Structure
Program mission, structure and financing, format for
delivery of co-occurring services
II
Program Milieu
Physical, social and cultural environment for persons
with mental health and substance use problems
III
Clinical
Process:[screening &]
Assessment
Processes for access and entry into services,
screening, assessment &diagnosis
IV
Clinical Process:
Treatment
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 co-occurring disorder issues
6
Dual Disorder Capability
Enhanced 5
(N=300)
4.5
Transformation of the Service System may be
said to occur when the majority of outpatient
clinics are rated capable or above
4
3.5
Capable
3.09
3.06
3
2.70
2.5
2.48
2.50
Program
Structure
Program Assessment Treatment
Milieu
2.53
2.76
2.47
2
1.5
Basic
1
Total Score
Continuity
of Care
Staffing
Training
Scores based on DDCA[MH]T = Dual Diagnosis Capability in addiction [Mental Health] Treatment Index
7
Program Structure
Recommendations
DDCA[MH]T Score
Enhanced – 5
 Ensure that the program’s licensure
agreement (or state permit) identifies the
target population as individuals with
substance related disorders (for addiction
clinics) or mental health disorders (for mental
health clinics) but does not restrict the
program from treating individuals with cooccurring mental disorders or substance use
disorders, respectively
4
Capable – 3
2
 Update agency mission statement (or develop
a program service statement) to reflect that
co-occurring services are provided
2.48
Basic – 1
Program Structure
 Demonstrate that your program’s system of
care meets the definition of collaboration; that
is, shared responsibility for treating a person
with co-occurring conditions, involving
regular and planned communication, and
shared progress reports or memoranda of
agreement
8
Program Milieu
Recommendations
DDCA[MH]T Score
 Ensure that materials for both
substance related and mental
disorders are posted and distributed
Enhanced – 5
4
 Engage in a discussion with staff
regarding "attitudes and values"
towards treatment of co-occurring
disorder
Capable – 3
2
 Expect and welcome clients with both
disorders
2.50
Basic – 1
Program Milieu
9
Clinical Process —
Screening (one item from Assessment Domain)
Recommendations
DDCA[MH]T Score
Enhanced – 5
 Establish a protocol that will direct all
those with a positive score on the screen
to an integrated assessment
4
Capable – 3
3.24
2
Basic – 1
 Implement one of the state-recommended
standardized screening instruments
(these are all free, brief, and do not require
clinical expertise to administer)
 Separate the screen from the assessment
protocol; the screen should drive the
assessment, but it is not a diagnostic
evaluation nor should it be used to
determine severity of a mental health or
substance use condition
Screening
(one item from Assessment Domain)
10
Clinical Process —
Assessment
Recommendations
DDCA[MH]T Score
Enhanced – 5
 Provide a comprehensive assessment that
covers all 12 recommended domains and
includes a thorough substance use and
mental health evaluation
 Obtain diagnostic evaluation as part of the
assessment process
 Build on the stages of change for both
disorders
4
Capable – 3
3.06
 Synthesize assessment information into
main problem areas that need to be
addressed
 Use assessment data to inform the
treatment plan
2
Basic – 1
Assessment
11
Clinical Process — Treatment
Integrated COD Services
DDCA[MH]T Score
Enhanced – 5
 Allow the free expression and discussion
of co-occurring problems in group and
individual sessions
 Ensure inclusion of mental health and
substance use content in all groups
 Create a “home” for co-occurring disorders
in the treatment schedule (i.e., offer a
psycho-educational class for COD and a
dual recovery group)
4
Capable – 3
2
Recommendations
2.53
 Provide supervision and coaching to
increase staff competency in COD
Basic – 1
Treatment: Integrated COD Services
12
Clinical Process — Treatment
Evidence Based Interventions
Data from OASAS
Local Service Plan (LSP) Survey
100%
 Organize treatment with a stage-wise
approach
 Build staff competencies in Motivational
Interviewing
 Employ existing trauma curriculums; for
example, Seeking Safety and Trauma
Recovery & Empowerment Model (TREM)
80%
60%
 Offer Wellness Self-Management
curriculum to integrate co-occurring
content further
40%
20%
Recommendations
24%
 Gradually introduce other NYS
recommended evidence-based
interventions
0%
Evidence-based
Interventions
13
Continuity of Care
DDCA[MH]T Score
Enhanced – 5
Recommendations
 Ensure that the discharge plans
address both the substance use and
mental health disorders
 Encourage and arrange connections to
community support groups during
treatment and as part of discharge
planning (e.g. Double Trouble in
Recovery, Dual Recovery Anonymous)
4
Capable – 3
2.76
2
 Provide a supply of medication
sufficient to span from discharge until
continuing treatment has been
established
Basic – 1
Continuity of Care
14
Staffing
DDCA[MH]T Score
Enhanced – 5
Recommendations
 Ensure that at least one direct care staff
member has mental health and substance
use competency or licensure
 Provide on–site clinical supervision
sessions that include a focus on cooccurring disorders
4
 Ensure that team meetings and case
reviews incorporate co-occurring
disorders
Capable – 3
3.09
2
Basic – 1
Staffing
15
Training
DDCA[MH]T Score
 Demonstrate that the program has a
written training plan
 Maintain and enhance staff competencies
in co-occurring services using up-to-date
literature, films, and other media, as well
as in-service and external trainings
Enhanced – 5
4
 Train staff in specialized treatment
approaches and pharmacotherapy
Capable – 3
2
Recommendation
2.47
Basic – 1
Training
16
Training —
Focus on Integrated Treatment
Recommendation
 Urge staff to enroll in FIT (Focus on Integrated Treatment) online learning
Description of FIT
 This training helps practitioners gain a firm foundation in evidence-based
integrated treatment for COD including screening and assessment, stagewise treatment, motivational interviewing, and more. Additional modules
help clinical supervisors develop their supervision skills and guide agency
leaders through changes to ensure sustainability of integrated treatment.
 Along with learning modules, CPI (the Center for Practice Innovation) offers
inline implementations supports through webinars, “Ask the Expert” forums,
and discussion threads.
 The training is comprised of 35 individual modules developed alongside
experts at the Dartmouth Psychiatric Research Center
http://www.practiceinnovations.org/CPIInitiatives/FocusonIntegragedTreatmentFIT/tabid/99/Default.asp
17
Training — TIP 42
Recommendation
Refer to and use TIP 42 and its
associatedin-service training curriculum
Description of TIP 42
1. Introduction
2. Definitions, Terms, & Classification
3. Systems for COD
4. Keys to Successful Programming
5. Assessment
6. Strategies for Working with Clients with COD
7. Traditional Settings & Models
8. Special Settings & Models
9. Special Settings & Specific Populations
10. A Brief Overview of Specific Mental Disorders & Cross-Cutting Issues
11. Substance-Induced Disorders
http://store.samhsa.gov/product/SMA08-3992
18
Improving Co-occurring Capability —
Quick Guide
10 recommendations for Getting to “Capable”
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Provide educational material for both disorders
Revise agency mission statement or develop a program service statement
Implement one of the NYS-recommended standardized screening instruments
Use assessment data to inform the treatment plan
Allow co-occurring concerns to be expressed and discussed in all group and
individual sessions
Ensure that all groups include mental health and substance use content
Offer a psycho-educational class on COD and a dual recovery group to create a
“home” for co-occurring disorders in the program schedule
Include both substance use and mental health treatment in discharge plans and
provide sufficient medication to last until continuing care has been established
Urge staff to enroll in FIT web-based learning
Refer to and use TIP 42 and its associated training curriculum
Easy to Employ & Conserves Resources
19
Improving Co-occurring Capability –
Quick Guide
Clinic Name:
Your Name:
Email:
Phone:
1. _________________________________________________________________________________________________________
Program Structure
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
1. _________________________________________________________________________________________________________
Program Milieu
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
Clinical Process:
Screening &
Assessment
Clinical Process:
Treatment
1. _________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
1. _________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
1. _________________________________________________________________________________________________________
Continuity of Care
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
1. _________________________________________________________________________________________________________
Staffing
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
1. _________________________________________________________________________________________________________
Training
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
20
Taskforce and Commissioners’
Recommendations
Screening
Instruments
For mental
disorders:
 Modified MINI Screen
(MMS)
 Mental Health Screening
Form III (MHSF III)
 K6 Screening Scale (K6)
For substance use
disorders:
 Modified Simple
Screening Instrument for
Substance Abuse
(MSSI-SA)
 CAGE Adapted to Include
Drugs (CAGE-AID)
 Alcohol, Smoking, and
Substance Involvement
Screening Test – v3
(ASSIST v3)
Assessment
Domains
Evidence-based
Interventions
For both disorders:
 Presenting problem[s]
 Current symptoms &
functioning
 Background
 Individual history
 Substance use
 Mental health
 Medical history
 Mental status
examination
 Client perception[s]
 Approved medications
For substance use
disorders:
 Evidence-based individual,
group, couples, and family
treatments –including
• motivational
enhancement
• CBT
• 12-step facilitation
• behavioral couples &
family therapy
• contingency management
 Cultural and linguistic
considerations
For mental illness:
 Supports & strengths
For serious mental
illness:
 Diagnostic
impressions on
5 DSM Axes
 CBT, medication
 Managing illness (IDDT,
education, medication, CBT)
family psychoeducation,
supported employment,
social skills training
 Peer support
21
Training & Technical Assistance Activities
Year 1,Year 2, Year 3(4th Quarter of Year 3 is projected)
250
250
12
Year 1 (Nov ’08 - Dec ’09)
Year 2 (Nov ’09 - Oct ’10)
Year 3 (Nov ’10 – Oct ’11)
10
11
200
200
8
8
200
165
150
150
6
4
2
5
100
100
5
4
4
3
3
86
50
50
0
0
0
0
DDCA[MH]T = Dual Diagnosis Capability in Addiction [Mental Health] Treatment Index22
CEIC TA Serviceshave been provided
in about ¾ of the state’s regions/counties
23
Dual Disorder Capability
Enhanced 5
(N=300)
4.5
4
Closer to
Capable
than to Basic
3.5
Capable
3.09
3.06
3
2.70
2.5
2.48
2.50
Program
Structure
Program Assessment Treatment
Milieu
2.53
2.76
2.47
2
1.5
Basic
1
Total Score
Continuity
of Care
Staffing
Training
Scores based on DDCA[MH]T = Dual Diagnosis Capability in addiction [Mental Health] Treatment Index
24
Dual Disorder Capability—
Percentage Capable
Enhanced 5
4.5
7%
4
3.5
21%
43% are near or
above Capable
Capable 3
15%
22%
2.5
30%
2
1.5
6%
Basic 1
Scores based on DDCA[MH]T = Dual Diagnosis Capability in Addiction [Mental Health] Treatment Index
25
Bi-annual OASAS EBP Survey
 Surveydesigned to obtain EBP integration by
implementation stages (Fixsen et al.)
 Added items on COD in collaboration with CEIC
(and NKI) to assess COD practices
 Sent to all OASAS certified programs
 Rated on a 5- point implementation scale
5. Sustainability
4. Innovation
3. Implementation
2. Installation
1. Exploration
 Employs drop-down menu of additional questions to
increase the accuracy of reporting
 Response rate 96% of all licensed programs
26
Local Services Plan (LSP) Survey
Tool(sample page)
27
Evidence-Based Practices and Evidence-Based
Interventions: Level of Implementation
5
Level of Implementation Scale:
5 = Sustainability
4 = Innovation
3 = Implementation
2 = Installation
1 = Exploration
0 = Not applicable (hasn’t moved to implement at all)
4.5
4
3.5
Screening
Assessment
Integrated
Services
3
Motivational
Interviewing
Cognitive
Behavioral
Therapy
Psychotropic
Medication
2.5
2
Mutual SelfHelp Group
1.5
Contingency
Management
1
Behavioral
Couples
Therapy
0.5
0
Practices
Interventions
28
Screening, Assessment, Integrated
ServicesBased on OASAS Survey (Level 5)
29
Evidence-Based Treatment for
CODBased on OASAS Survey (Level 5)
About ¼
regularly employ
evidence-based
interventions
23%
Total
Motivational
Interviewing
Cognitive
Behavioral
Therapy
Contingency
Management
Behavioral
Couples
Therapy
Mutual
Self-help
30
Comparative Survey Results
31
Strategic Plan —
Reach & Penetration
The strategic plan to reach & penetrate more than 1,000 outpatient substance abuse & mental health clinics over 4 years
Direct (“hands-on”)
Technical
Assistance
• DRCs
• FIT
• Regional / County
Networks
amplifies Direct TA and promotes Sustainability
32
Evaluation Plan
How will we know the system status?
1)
Follow up DDCA[MH]T survey on representative
sample
2)
Follow up on OASAS survey — planned for 2012
3)
Analysis combining these data sources
(as briefly illustrated here)
4)
Focus groups
5)
Case studies
6)
Brief web-based survey
33
Recent Developments
Integrated Services – Nassau County to integrate services both within
clinics and across the service system
Video – creating a video on building COD capability in the areas of
Screening, Assessment and Evidence-Based Practices called
“Getting to Capable”
Manuscript – writing a descriptive study of the current status of the
system for publication
New Instrument – developing and refining an instrument to measure
recovery-oriented services integration with NYAPRS
New Instrument – developing and field testing an instrument with
Dr. Mark McGovern to measure the degree to which primary health
care services have been integrated with mental health and
substance use interventions. This has particular significance for
health care reform.
34
Summary
 There exists a clear and increasingly positive picture of the status of
OMH and OASAS outpatient clinics regarding evidence based
practices and interventions




45% for screening
40% for assessment
⅓ for integrated services
¼ for evidence based interventions
 The potential for advancement is greatest in the domains of
Program Structure, Milieu, Treatment, Training and Continuity of
Care, areas where certain improvements are considered to be fairly
easy to achieve given the current status of staffing and resources
 Transformation of the Service System may be said to occur when
the majority of outpatient clinics are rated capable or above
OMH and OASAS outpatient clinics are moving toward
a COD capable status
35
Conclusion
The project is significant in its:
 Promise of improving the health of NYS residents
with co-occurring conditions
 Potential to reduce health disparities
 Ability to inform allocation of resources
 Capacity to effect system transformation in the
delivery of services
 Implications for health care reform:
 Identifying capable programs
 Illustrating methods and approaches for advancing
integration
36
Contact Information
Stanley Sacks, PHD, Director
Center for the Integration of Research & Practice (CIRP) & Center for Excellence in Integrated Care (CEIC)
National Development & Research Institutes, Inc. (NDRI)
71 W 23rd Street, 8th Floor
New York, NY 10010
TF 877.888.6677 tel 212.845.4400  fax 212.845.4650
www.nyshealth-ceic.orgwww.ndri.org
Michael Chaple, PHD, Deputy Director
Center for the Integration of Research & Practice (CIRP) & Center for Excellence in Integrated Care (CEIC)
National Development & Research Institutes, Inc. (NDRI)
71 W 23rd Street, 8th Floor
New York, NY 10010
TF 877.888.6677 tel 212.845.4400  fax 212.845.4650
www.nyshealth-ceic.orgwww.ndri.org
ChackuMathai, CPRP, Associate Executive Director
New York Association of Psychiatric Rehabilitation Services
1 Columbia Place, 2nd Floor
Albany, NY 12207
tel 518.436.0008
www.nyaprs.org
CEICreceives support (awards 2008-2496857 & 2009-3426912)
from the New York State Health Foundation
37