Using An Assessment Tool as a
Way to Improve COD Services
Healthcare Integration
Darien De Lu, Dept. of Alcohol and Drug Programs,
Co-Occurring Disorders Program with funding from
the California Mental Health Services Act
1
Financial
challenges
bring a
treatment
crisis
which
demands a
response…
2
Under healthcare reform, new pressure
for substance abuse (SA) and mental
health (MH) tx to integrate with
primary medical care.
• SA and MH issues drive health care
costs, making integration with primary
care all the more cost effective.
• Chronic and relapsing conditions –
including SA and MH – especially call for
a continuing care model.
3
A Continuing Care Model
Primary Care
Specialty Care
Primary
Continuing Care
4
Preparing for a Changing System
What will help us develop a
successful continuing care model,
with the high quality treatment that
can attract the cooperation of
primary care providers required
under health care reform (HCR) –
especially for a relapsing illness like
Co-Occurring Disorders (COD)?
5
Use of the DDCAT or DDCMHT (Dual
Diagnosis Capability in Treatment –
Addiction or Mental Health)
assessment tools can support improved
treatment for COD, including both
integrated tx and continuing care.
6
Integrated Treatment and
Treatment Integration
• Under Parity legislation and HCR –
and to achieve savings – Federally
Qualified Health Care Homes and
others will emphasize integration of
medical tx with AOD and MH tx.
• SAMHSA and others recommend
integrated AOD and MH tx for COD.
7
Why use the DDCAT/DDCMHT?
• Use of the these assessment tools
presents programs with information on
quality COD tx in a format that allows
and encourages improvement.
• The workforce development and other
tx improvements that the DDCAT/MHT
encourage can help providers prepare
for Health Care Reform changes.
8
What is COD?
COD used to be the same as
“dual diagnosis” (DD), referring
only to SA combined with MH
issues.
Now – under HCR – the definition is
expanding to refer to co-occurring
chronic medical conditions, such as
diabetes, asthma, and HIV.
9
Old COD and New COD
• Many of those with DD – the “old
COD” – also have chronic medical
conditions, the “new COD”.
• For this presentation, “COD” will
refer to the “old COD” of DD . But
the “new COD”, including DD, is
critical to address for cost control in
HCR and integrated health care!
10
How widespread are COD?
• Approximately one-half of the
people who have a MH or a SA
disorder also have the other
COD/DD condition. (SAMHSA statistic).
• Partly due to poor management of
chronic medical conditions, those with
COD live 20 years fewer than average.
11
Examples of COD
• Teen experiences long-term depression
over parents’ divorce; to keep weight
down “purges” (bulimia nervosa) then
takes methamphetamines and drinks
alcohol to feel better.
• Iraq vet returns home with visions of
friends blown up in war; is socially
isolated & seriously depressed, drinks
until blacks out, and has attempted
suicide twice.
12
Integrated COD Treatment
SAMHSA recommends integrated
treatment for those with COD:
Integrated Treatment =
Simultaneous and Co-ordinated
(usually, via case management)
SA Treatment and MH Treatment
13
Past Year Treatment Among Adults with Co-occurring
Serious Psychological Distress and Substance Use
Disorder
Treatment for Both Mental Health
and Substance Use Problems
8.5%
Treatment
Only for
Mental
Health
Problems
Substance
Use
Treatment Only
4.1%
34.3%
53.0%
No Treatment
(SAMHSA, 2006)
14
“Availability of comprehensively integrated
treatment for mental health and substance
abuse problems is currently the exception
rather than the rule. The unmet need for
integrated mental health, alcohol and drug
abuse treatment in underserved racial and
ethnic communities is even greater.”
California Mental Health Services Oversight
and Accountability Commission (MHSOAC)
Report on COD
15
Costs of Untreated or
Improperly Treated COD
• Medicaid (a driver in HCR)
• Children’s and Adult Protective Services
• CA Dept. of Corrections & Rehabilitation,
(as high as 80% of substance abuse clients
are assessed to have COD - State survey),
county jails, juvenile hall
• Education (increased demands on system)
• Housing, homeless shelters
• Foster Care system (parents with COD)
16
COD Clients Experience Poorer Outcomes:
Persons with COD “have more medical
problems, poorer treatment outcomes,
greater social consequences and lower
quality of life.” (MHSA Report)
• One study of 121 clients with psychoses
found that those with substance abuse
problems (36%) spent twice as many days in
the hospital over the 2 years prior to
treatment as clients without these problems
(Crome 1999; Menezes et al. 1996).
17
Additional Co-Occurring Conditions
• COD clients also often have other poorer
outcomes, such as higher rates of –
– HIV infection
– relapse
– depression
– suicide risk
– rehospitalization
(Office of the Surgeon General 1999, Drake et al. 1998)
18
Primary
Care
Screen
Intervene
Monitor
Refer
relapse
Continuing Care for
COD: Relapsing
Specialty Care:
Integrated
MH & AOD Tx
Stabilize
Motivate/Medicate
Train Self-Management
Re-Intervene
Continuing Care
& Other Services Monitor/Support
19
The DDCAT/MHT Assesses Capability in
COD Tx, Emphasizing Integrated Tx
An easy-to-use fidelity instrument that –
• Focuses on evidence-based practices
• Allows a program to see where its services fit
among specific better and worse practices.
• Provides a baseline for future assessments.
• Encourages, through its structure and
modeling, improvements and Action Plans.
20
Quality COD Treatment
Meshes Well with HCR
• A welcoming, supportive, culturally
sensitive, and structured program
• Identifying COD clients by use of
screening tools and, as indicated,
appropriate assessment
• Tx plans that are integrated and
coordinated for both SA & MH tx
21
Quality COD Treatment & HCR, cont.
• A trained workforce of skilled direct
care staff/counselors to do
assessments, tx plans, and tx that
meets client needs
• Building collaborative partnerships
to access professionals to program
supplement staff
22
Quality COD Treatment & HCR, cont.
• COD tx policies and procedures in
place
• Continuity of Care throughout tx
and upon discharge, including
encouragement of support groups.
• After-care resources and referral for
both diagnoses
23
Program Response to
the Use of the DDCAT Survey
“I would recommend this process
to any AOD treatment facility
who wants to enhance or support
their process in dealing with
those with co-occurring
disorders.”
Program Director, one Pilot Project facility
24
You Can Encourage the Use of
the DDCAT/MHT!
• Inform programs: They can voluntarily
do a DDCAT/ DDCMHT self-assessment.
Download the free tool at the COD site:
http://www.adp.ca.gov/COD/ddcat.shtml
• After self-assessment, programs can use
the resulting information to create their
own Action Plan = Better COD Tx, Lower
Healthcare Costs
25
Training in the DDCAT & DDCMHT
• These tools can be usefully employed without
further training. However, training in them is
helpful both –
– to obtain accurate results and
– to reinforce the DDCAT/MHT information on
components of quality tx capability.
• The COD DDCAT website features DDCAT training
materials for you to download. The two tools are
extremely similar, so that training in one generally
applies to the other.
26
The Goals:
Improved COD Treatment,
Better Preparation for HCR
COD is a serious and wide-spread
relapsing condition entailing substantial
impacts on public services, so treatment
improvements call for a continuing and
integrated care approach to integrated
tx, like the DDCAT and DDCMHT model.
YOU CAN MAKE A DIFFERENCE!
27
The beginning of wellness for all!
For further info, contact
DDeLu@adp.CA.gov or KFurey@adp.CA.gov
http://www.adp.ca.gov/COD/ddcat.shtml
28