Innovations in the
Identification and Treatment
of Co-Occurring Mental Health
and Substance Misuse Disorders
Berks County MH/MR Board
November 9, 2009
Historical Context in PA
PA MISA
Consortium
Established
PA MISA
Consortium
Report
MISA Pilot
Project
Report
1997
1999
2004
Following report,
DOH and DPW
issued solicitation
to counties for
MISA Pilot Proposals
(18 received,
5 selected - Berks)
Joint Bulletin
issued by
DPW and DOH
for Co-Occurring
Disorder
Competency
Approval Criteria
Moratorium
placed on DOH
and DPW COD
Competency site
reviews until
formal protocols
developed
2006
2008
Community Care Efforts
in Berks County
• 2001 HealthChoices BH MCO contract for Berks
• Began conducting MISA screening trainings with
network providers and gathering MISA information
during utilization reviews and on OP registration
forms in 2003
• Annual Membership Analysis includes dual
diagnosis analysis
• Contract with providers licensed
by DOH and DPW, including
one involved in MISA Pilot Project
MISA Screening Requirements
• Providers must complete screenings on all
members age 14 and older who are receiving
mental health or substance abuse treatment.
• Screenings are encouraged for children
younger than 13 for co-occurring mental
health and substance abuse disorders, as well
as screening for any mental health or
substance abuse problems in the family.
Goals
• Enhance Level/Degree of Screening and
Assessment
• Enhance Treatment/Service Planning
• Better Engagement of MISA Clients
• Expand Service Continuum
• Optimize Matching of Needs and Services
• Establish Accountability
Outcomes
•
•
•
•
•
•
Better substance use clinical outcomes
Better mental health clinical outcomes
Improvement in psychosocial functioning
Lower rates of high-risk behaviors
Lower relapse rates
Lower readmission rates
Quadrant 1
Low severity MH
Low severity AOD
Quadrant 2
High severity MH
Low severity AOD
Quadrant 3
Low severity MH
High severity AOD
Quadrant 4
High severity MH
High severity AOD
Quadrant 1
• Intervention in outpatient setting
• Discontinuation of substance use via
o/p contract
• Medication as indicated for possible MH
• Emphasis on stress management and
problem solving
Quadrant 2
• For severe MH, possible in-patient
services
• Continuing case management in MH
system
• Medication as indicated for MH
• Support programs as indicated
Quadrant 3
• For substance use exacerbations, may
need detox
• Out-patient counseling in AOD or MH
depending upon level of dual diagnosis
• Integrated systems
• Medication for MH as indicated
Quadrant 4
•
•
•
•
In-patient or detox services as indicated
Continuing case management
Support programs as indicated
Integrated systems
2009 Membership Analysis
• Among Berks HealthChoices members in
treatment in 2008:
– 94% had a MH diagnosis, 19% had SA diagnosis,
and 12% had both MH and SA diagnoses
– 13% of members with MH diagnoses also had a
co-occurring SA diagnosis
– 65% of members with SA diagnosis also had a
co-occurring MH diagnosis
Larger proportion of substance use disorders are treated within the
context of co-occurring disorders in Berks County compared to the
aggregate of all HealthChoices members (58%)
D&A=19%;
MH=94%
D&A
MH
Dual DX = 12%
Analysis Continued - Gender
Mental Health
Diagnosis
Substance
Related
Diagnosis
Co-Occurring
Female
95%
16%
11%
Male
92%
21%
13%
Analysis Continued - Age
Mental Health
Diagnosis
Substance
Related
Diagnosis
Co-Occurring
0-4
100%
0%
0%
5-19
98.5%
4%
3%
20-34
87%
32%
20%
35-64
91%
28%
20%
65 & older
95%
6%
<2%
Analysis Continued – Race
Substance Related
Diagnosis
Co-Occurring
White
22%
16%
African-American
30%
28%
Asian
14%
8%
Native American
30%
23%
Other
14%
8%
• MH Diagnoses show fairly even distribution across race
(range between 89% - 95%)
Analysis Continued - Ethnicity
Hispanic
Non-Hispanic
Mental Health
Diagnosis
Substance
Related
Diagnosis
Co-Occurring
96%
12%
8%
93%
21%
13%
• Slightly larger proportion of substance use disorders
identified within context of co-occurring disorders for
both Hispanic and non-Hispanic populations in Berks
compared to aggregate
Providers Contracted
for MH and SA Services
Provider
MH Services
SA Services
Berks Counseling
Center
OP, MMHT, Peer
Specialist
OP, IOP, TCM,
Buprenorphine
Family Guidance
Center
OP, MMHT
OP
New Directions
Treatment Services
OP
OP, Methadone
Maintenance
Pennsylvania
Counseling Services
OP, BHRS, FB
OP, IOP
Reading Hospital &
Medical Center
OP, Partial, IP, ACT
OP, IOP, Detox,
Rehab
Dual Diagnosis Services
• Berks Counseling Center is only provider
contracted for dual diagnosis services
• Distinct modifiers established under OP
DA services – Individual, Family, Group,
IOP
• BCC is reimbursed at an enhanced rate for
OP (20% higher than base fee schedule)
• BCC served 380 unique members in 2008
BCC Utilization in 2008
Age Group
Number
Percentage
Adolescents
28
7.4%
Adults
352
92.6%
0
0%
380
100%
Seniors
Total
Race
Number
Percentage
White
193
50.8%
Other
113
29.7%
African-American
70
18.4%
Hispanic or Latino
2
0.5%
Native American
2
0.5%
380
100%
Total
Gaps in Co-Occurring Treatment
• Majority of services continue to be offered
through a parallel treatment approach
• Members sent out of county for dual
diagnosis inpatient services
• Adolescents under served
• Lack of funding to develop
and reimburse for integrated
services
Opportunities for Improvement
• Establish singly licensed programs to
provide integrated treatment
• Utilize PA Co-Occurring Competency
Standards for program development
• Develop integrated treatment approaches
• Expand service continuum
• Target adolescent population
Next Steps
• Assessment of cultural competence/
awareness
• Assessment of consumer outcome
• Capacity building
• Development of
improved engagement
strategies