Supporting Individuals with
Intellectual and Mental Health Needs
A framework for Inter – Systems Collaboration
Dr. Robert J. Fletcher
Founder and CEO, NADD
North Bay Regional Center
March 8, 2012
Outline of Presentation
Barriers to Service Delivery
At the National Level :
Working Together or Not
Principles in Service Planning
A Framework to Promote Cross System
Collaboration
Dual Diagnosis Policy Issues
The Typical Picture:
Individuals with MI and ID are
among the most challenging
persons served by both MH and
ID Service Delivery Systems
Fletcher, 2008
Dual Diagnosis Policy Issues
The Typical Picture:

Failure to plan services

Failure to fund flexible services

Failure to obtain technical
assistance
Fletcher, 2008
Dual Diagnosis Policy Issues
The Typical Picture:

Failure to provide adequate training
and technology transfer

Failure to share and assume joint
responsibility

Failure to articulate a policy
Fletcher, 2008
Dual Diagnosis Policy Issues
The Typical Picture:

MH providers perceive that they do not
have the skills to serve adults or
children with a dual diagnosis

DD providers do not understand the
services that the MH sector offers

MH providers do not understand the
services that the DD sector offers
Fletcher, 2008
Dual Diagnosis Policy Issues
People with MI and ID typically require:
 Professional
staff with specialized
clinical experience
 Comprehensive
 Presence
service coordination
of consistent backup
support
 Living
requirements with fewer people
NASDDS Survey, 2004
Dual Diagnosis Policy Issues
MH System
 Short term episodic
treatment
 Focus on psychiatric
needs
 Recovery model
 Local authority
 Medication Treatment
 Consumer/Client
/Patient
DD System
 Services/supports over
lifetime
 Emphasis on direct
support
 Self Determination
 State authority
 Behavioral Support
(PBS)
 Self – Advocate/
Consumer
Little Collaboration
Fletcher, 2008
Dual Diagnosis Principles

Co-occurring disorders should be
treated as multiple primary disorders,
in which each disorder receives
specific and appropriate services.

Collaboration of appropriate services
and supports must occur as needs
are identified.
Fletcher, 2008
Dual Diagnosis Principles

Service collaboration between
systems is essential

Services provided to the individual
are consistent with what the person
wants and what supports are
needed
Fletcher, 2008
Dual Diagnosis Principles

Services are determined on the basis
of comprehensive assessment of both
MH and DD needs of each individual

Services are based on individual
needs and not solely on either MH or
ID diagnosis
Fletcher, 2008
Dual Diagnosis Principles
 Emphasize
early identification and
intervention
 Involve
the person and family as full
partners
 Coordinate
at the system and service
delivery level.
Fletcher, 2008
Dual Diagnosis Principles

The whole system must be
designed to be welcoming and
accessible to people with cooccurring disorders

People with co-occurring disorders
shall be supported in the least
restrictive environment.
Fletcher, 2008
Dual Diagnosis Principles

People with co-occurring disorders
and their significant others, when
appropriate, shall be empowered to
make treatment decisions.

The system recognizes and values the
long-term cost effectiveness of
providing best practice services and
supports for persons with cooccurring disorders.
Fletcher, 2008
Working Together or Not
In 65% of states, policy is developed in
collaboration with other state agencies

Relationships with
Mental Health
55% Effective, very
effective or
extremely effective
 45% Not or not very
effective


Relationships with
Corrections



NASDDDS, 2011
73% Not or not very
effective
22% Effective
5% Very effective
Working Together or Not
Financial Operations

Operational authorities
State governments
 Local counties and municipalities
 Regional boards


Medicaid and Medicare funding


Medicaid covers 75% - 95% of costs for DD
services, limited MH supports
Some potential under Medicare
NASDDDS, 2011
Working Together or Not
In general, . . .

DD has primary
responsibility for
long term support
in 70% of states

NASDDDS, 2011
MH has primary
responsibility for
psychiatric care
in 78% of states
Working Together or Not
MH State Plan Services are available,
But access is frequently difficult…..

MH programs are:
 Under – funded
 Stretched to the limit
 Lack expertise to meet needs of people with
ID / DD
 Unable to bill for necessary activities
 Include structural barriers
NASDDDS, 2011
Working Together or Not
Emergency Support and Response
in 13 States

DD exclusively in
5 of 13 states
(38%)

MH exclusively in
3 of 13 states
(24%)

Mixed in 5 states (38%)
 Usually MH but DD
may support
 Usually DD but MH
may support
 DD provides but MH
contributes funding
NASDDDS, 2011
Working Together or Not
Top Barriers in 2010





Availability of funding, targeted flexible dollars
Providers with sufficient expertise and interest
Access to appropriate psychiatric treatment
and related services
Lack of trained staff MH and DD staff
Effective and timely crisis supports
NASDDDS, 2011
Working Together or Not
Effective Practice Elements

Leadership
Commitment
 Clear lines of
authority
 Independence
 Protection
 Commitment to
collaboration
 Focus on the
Individual

The person-centered
planning process must
determine what is
important TO the
person and what is
important FOR the
person.
- Michael Smull
NASDDDS, 2011
Working Together or Not
Essential Elements…..

The right person
 The right match
 Build trust,
dependability



Training
 Coordination

Effective Staff
Focus on the
System
DD/MH interface
Its not a matter of showing
up – it is who shows up. It
must be someone with
commitment and interest in
the individual. Someone
who cares.
- David Petonyak
NASDDDS, 2011
Working Together or Not
Effective Treatment

Timely Access to:
Appropriate psychiatric treatment and
medication management
 Positive Behavioral analysis and supports
 Effective treatment strategies such as dialectical
behavior therapy, EMDR, etc.
 Community services, supports and resources
 Employment and meaningful opportunities to
participate in community life
 Supports in home and with family

NASDDDS, 2011
Working Together or Not
Top New Initiatives and Good Ideas








Expanding Community Support Teams
Developing new psychiatric practice standards
Increasing DD expertise among MH
Establishing Centers for Excellence for training,
leadership and technical assistance
Deinstitutionalization creates opportunities
Developing capacities through university programs
Cross-System Planning Formats
Strengthening crisis supports
NASDDDS, 2011
A Framework To Promote Cross
Systems Collaboration
Cross Systems
Task Force/Committee
Fletcher - 2008
Cross Systems Collaboration
Mission of a Dual Diagnosis Task
Force/Committee
A Cross System Task Force is a mechanism to
draw attention to and make recommendations
about, policy and services for individuals with
ID and MH needs
Fletcher, 2008
Cross Systems Collaboration
Purpose/Function of A Dual Diagnosis Task
Force/Committee
 Gather relevant data/formation
 Identify strengths in service delivery systems
 Identify challenges in service delivery system
Fletcher, 2008
Cross Systems Collaboration
Purpose/Function of A Dual Diagnosis Task
Force/Committee
 Generate options for improvement in service
delivery systems
 Promote cross systems education/training to
enhance staff competencies
 Advocate for policy initiative that advance
cross systems collaboration
Fletcher, 2008
Cross Systems Collaboration
Composition Of A Dual Diagnosis Task
Force/Committee
 Representatives from Mental Health
Departments
 Representatives from ID/DD Departments
 Representatives from provider agencies
 Family/consumer/advocate representatives
Fletcher, 2008
Cross Systems Collaboration
Stakeholders from other than MH & IDD systems
could be included as appropriate, perhaps on an “as
needed” basis. These include, but are not limited to
representatives from:




Substance abuse
Criminal Justice
Health Department
Social Services




Fletcher, 2008
Education
Early Intervention
Child Welfare
Coordinated Children’s
Services
Five Aspects Of A Coordinated
Care System
1.
Collaboration
2.
Comprehensiveness
3.
Flexibility
4.
Continuity
5.
Leadership and Partnership
Adapted from Kline, et al, 1993
Coordinated Care System
1.
Service Collaboration:

Policy level – linkage

Program level – integrated

Individual level – personcentered coordination
Adapted from Kine, et al, 1993
Coordinated Care System
2.
Comprehensiveness
No One System Can Serve All People
with MH/ID
Mental Health
MH/DD
Child & Family
Health
Education
Social Services
Substance Abuse
Criminal Justice
Adapted from Kine, et al, 1993
Coordinated Care System
Mental Health
PERSON
MR-DD
Fletcher, 2007
Coordinated Care System
3. Flexibility
Flexible Enough to Modify Traditional
Approaches
Sufficient flexibility for:

increase time/resources in assessments
 cross training
 modification of traditional approaches
Adapted from Kine, et al, 1993
Coordinated Care System
4. Continuity
Keep an eye on:
 changing needs

changing systems

propensity for behavioral problems

need for long term treatment &
supports

need to focus on multiple systems in
different contexts over a life span
Adapted from Kine, et al, 1993
Coordinated Care System
5. Leadership and Partnership




Partnership across systems
Need leadership to facilitate
coordination
Ensure accountability
Political will
Adapted from Kine, et al, 1993
Other Policy Recommendations
Other Important Aspects of Policy Development:
 Children and Adolescent Issues
 Cross Systems Training
 Cross Systems Crisis Intervention Service
 Consultation and Treatment
 Cross System Coordination: State/Local
Level
US HHS, 2005
Children & Adolescent Issues
 Train teachers, other professionals, and
parents to recognize signs and symptoms of
ED in children with ID
 Improve transitional planning from school to
adult systems system operations:
Fletcher, 2007
Training Issues
Need Cross-Systems Training
 Mutual understanding of different culture,
language and philosophy
 Acquire knowledge regarding how the other
system operations:
- eligibility
- funding
- assessment
- structure
 Learn how habititative/treatment strategies are
different from one system to another
Fletcher, 2008
Crises Intervention Service
A Cross System Approach
1. Provide short term crisis intervention with
the goal of minimizing a need for
hospitalization, crisis residential care or outof-home placement
2. Staff from crisis service interacts with all
appropriate systems
Fletcher, 2008
Consultation & Treatment Issues
 Bio-Psycho social model in
assessment
 Rationale psychopharmacology
 Integrating mental health treatment
with behavioral approaches
 Effective cross-systems transitional
services
 Modifying individual and group
therapy
Fletcher, 2008
Cross Systems Planning & Coordination
State and Local
 Planning and coordination at local
level
 Planning and coordination at state
level
 Planning and coordination between
local and state level
Fletcher, 2008
Treat Collaboration as Seriously as You
Do Your Budget
If you need
expert assistance
to forge
collaboration,
get it!
Service Planning and Policy

Plan cross systems services strategically

Design flexible service models that can change
over time as individual needs change

Obtain technical assistance

Provide cross systems training to enhance
agency and practitioner competencies

Provide incentives for assuming and sharing
responsibility
J. Jacobson, 2003
Collaboration Strategies
 Identify and clearly state specific purposes
for collaboration
 Allow time to consider all provisions, so that
final decisions will be more fully supported
 Negotiate written agreements for
organizational responsibilities, program
design, fiscal arrangements, and established
time frames
Ament, 1987
Collaboration Means Sharing
Resources and Authority
Make sure that each organization understands what it
brings to the collaboration and reach a middle ground.
ID/MI Discussion Matrix
State
How are
you
doing
now?
How
could
you
improve
over the
next
year?
What
plans
can you
make for
the next
1-3
years?
Regional
County
Staff
Training
Clinical
Quality
Advocacy
/Other
ID/MI Action Plan
Action to be
Taken
System
Strategies
State
Regional
County
Staff
Training
Clinical
Quality
Advocacy/
Other
Resources Needed Date of Expected
to Complete
Completion
Action
Responsibility
Person(s)
Organization(s)
THANK YOU!
For more information, please contact:
Dr. Robert J. Fletcher
NADD
132 Fair Street, Kingston, NY 12401
Telephone: 845-331-4336
E-mail: rfletcher@thenadd.org
Web site: www.thenadd.org