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1 DUAL DIAGNOSIS CAPABILITY IN ADDICTION TREATMENT (DDCAT) VERSION 2.4 Mental Health version rev. 5/25/06 by Heather Gotham RATING SCALE COVER SHEET Date: Rater(s): Time Spent: Agency Name: Program Name: Program Type(s): Level of Care: Address: Contact Person: (Title: ) Telephone: ; FAX: ; Sources used: Chart Review Agency brochure review Program manual review Team meeting observation Supervision observation Observe group/individual session Interview with Program Director Interview with Clinicians Interview with clients (#: ) Interview with other service providers (Specify: ) Physical site tour/observation Total # of sources used: Notes: 1

2 I. PROGRAM STRUCTURE IA. Primary treatment focus as stated in MI Only If materials talk about Behavioral Health mission statement. Printed mission statement Primary focus is MI, cooccurring disorders are treated Primary focus on dualdiagnosis patients. IB. Organizational certification & Permits only MI treatment No actual barrier, but staff report certification or licensure barriers. Has no barrier to providing addiction treatment licensure. What does licensure/certification permit? Are there impediments to providing certain types of services? Are these impediments real? Is certified and/or licensed to provide both IC. Coordination and collaboration with addiction services. No document of formal coordination or collaboration. Vague, undocumented, or informal relationship with addiction agencies, or consulting with a staff member from that agency. Formalized and documented coordination or collaboration with addiction agency. Formalized coordination & collaboration, and the availability of case management staff, or staff exchange programs (variably used) (staff has handle on tx course in both programs) Most services integrated within the existing program, or routine use of case management staff or staff exchange programs. How and where are SA services provided? Through relationships or integrated? Are these relationships formalized and documented? Are there letters of agreement/documented collaborations? ID. Financial incentives. Can only bill for MI treatments or for persons with MI. Can bill for either service type, however, MI must be primary. How do billing structures limit or incentivize services for persons with SA and/or MI disorders? Can bill for SA or MI treatments, or the combination/integration. 2

3 II. PROGRAM MILIEU IIA. Routine expectation of and welcome to treatment Expect MI only, refer or deflect SA. CODs not expected, nor plans documented. Documented to expect MI only, but will not deflect SA disorders. for both disorders What clients are expected and welcomed? How common are clients with COD? Expect MHs, and accept SA by routine and if relatively stable. Clinicians and program expects and treats both disorders, not well documented. Documented in mission statement, or program philosophy. Documents: How is this reflected in agency documents (mission statement, purpose)? IIB. Display and distribution of literature and patient MI only Available for both disorders but not routinely offered or formally available. Available for both MI & SA disorders. educational materials. What kind of information is posted on walls, on display in waiting areas and included in patient and family handouts and printed materials? Available for the interaction between both MI and SA disorders. Printed Materials: III. CLINICAL PROCESS: ASSESSMENT IIIA. Routine Pre-admission screening screening methods for based on patient selfreport: Decision based addiction on clinician inference from patient presentation or history. Pre-admission screening for SA & treatment history, Are there routines or systems to screen for addiction? Are screening instruments used? Clinicians have routine set of standard interview questions using generic framework: Biopsychosocial data collection. (if dx, tx history & quantity/frequency of use) Standardized or formal instruments with established psychometric properties. (e.g., CAGE, MAST) 3

4 IIIB. Routine assessment if screened positive for SA Ongoing monitoring for appropriateness or exclusion from program Biopsychosocial assessment, mental status exam, each clinician driven Formal assessment on site by SA professional as necessary (ASI, dx impressions or DSM) If a client screens positive, are more detailed assessments triggered? Are these assessments formalized and integrated? IIIC. Psychiatric and substance use diagnoses made and SA diagnoses are not made or recorded Off site professional may make diagnosis recorded in chart Diagnosis made on site, recorded in chart. (Variable). documented. If assessments are conducted, are SA disorder diagnoses made in addition to the psychiatric diagnoses? IIID. Psychiatric and substance use history reflected in medical record. Not present Variable by individual clinician. Routine documentation in record in narrative section. Are the chronologies and treatment course of disorders gathered (and recorded)? Standardized or formal integrated assessment is routine in all cases. Standard & routine diagnoses Specific section in record devoted to history and chronology of course of both disorders. 4

5 IIIE. Service matching based on SA sx acuity: low, moderate, high. Can provide care to persons with no to low acuity. Can provide care to persons with low to moderate acuity, but primarily stable. Can provide care to persons with moderate to high acuity, including those who have not quit What happens to clients who present for treatment with stable SA, or unstable? What about clients who are referred to MI treatment by their sub abuse treatment program? IIIF. Service matching based on severity of persistence and disability: low, Can provide care to persons with no to low severity of persistence of disability Can provide care to persons with low to moderate severity. Can provide care to persons with moderate to high severity moderate, high. What happens to clients who present with histories or reports of severe and/or chronic SA? (If no collaboration has ever been mentioned, might ask: Do you ever send them to a collaborative SA agency for treatment?) IIIG. Stage-wise treatment-initial. Not assessed or documented. Assessed & documented variably by individual clinician Clinician assessed and documented routinely, used in planning. Is stage of motivation assessed and documented? Does it influence what treatment a client gets or how s/he is approached? Formal measure used, & integrated in treatment planning 5

6 IV. CLINICAL PROCESS: TREATMENT IVA. Treatment plans. Address MH only (addiction not listed) Variable by individual clinician MH primary, SA as secondary Do treatment plans show an equivalent, integrated focus on SA and MIs, or do they primarily focus on MIs only? Systematic focus available but variably used. Address both as primary, both listed in plan IVB. Assess and monitor interactive courses of both disorders. No attention or documentation of progress with SA problems Variable by individual clinician reports of progress on SA problems (acknowledge up front, then no more) Clinical focus in narrative on SA problem change Are changes and/or progress with status and symptoms of both psychiatric and SA disorders followed (and noted)? Systematic focus is available but variably used. Clear, detailed, and systematic focus on change in both SA and MH IVC. Procedures for intoxicated/high clients, detox, and relapse or active users. Few documented or explicit in-house guidelines Explicit or verbally conveyed in-house guidelines. Explicit or documented guidelines: Referral or collaborations (to local SA agency or E/R) (clear communication back and forth) Routine capability, or a process to ascertain risk with ongoing use of substances: Maintain in program unless alternative placement is warranted Are there definite protocols for clients who arrive for treatment high/intoxicated and/or those at high-risk? What procedures do you have in place if you send your patients to a SA emergency provider such as detox? Do you receive feedback from detox? 6

7 IVD. Stage-wise treatment-ongoing. Not assessed or explicit in plan. Documented variably by individual clinician Individualized plan, no specific stage-wise treatments. Is stage of motivation assessed on an ongoing basis? Can treatment be revised based upon changes in motivation? Do you refer clients to AA? What about detox programs? How do you deal with clients who appear unwilling to change? (Probe for whether confrontation is used) What kind of relapse prevention skills do you teach? Do you teach relapse prevention skills to clients who are actively using drugs/alcohol? Formally prescribed stage-wise treatments. IVE. Policies and procedures for medication evaluation, management, monitoring and compliance. Prescribe MH meds w/active SA, -Work closely with team/client, -Increase adherence, -No benzos/addictive, -Use Patients on meds routinely not accepted Certain types of meds are not acceptable. Or must have own supply for entire treatment episode Present, coordinated medication policies for consultant provider. SA meds, Are medications acceptable? Are certain medications unacceptable? Are medications routine and integrated? Clear standards and routine for medicating provider who is also a staff member. Clear standards and routine for medicating provider who is also a staff member and present on treatment teams or administration. Are psychotropic medications prescribed to clients with active SA problems? How many active clients are currently taking psychotropic medications? Have any dual clients been prescribed benzodiazepines, clozapine to reduce addiction, antabuse, disulfiram, or naltrexone? How often do you contact your clients prescriber? What kind of strategies do you use for clients who do not take medications as prescribed? 7

8 IVF. Specialized interventions with SA content. Not addressed in program content Based on judgment by individual clinician Are therapies available that focus on addiction only? Ask about specifics from above In program format as generalized intervention Some specialized interventions by specifically trained clinicians. General & specialized interventions plus resource intensive services (e.g., intensive case management) IVG. Education about SA & treatment; interaction with MI & No Variably Present in generic format and content. (relation b/w disorders, OK to take meds) treatment. Is information available on how SA impacts an MI and vice versa? Do you have groups that address both MI and SA? How many clients attend such a group regularly? Present specific content for specific disorder comorbidities. IVH. Family education and support. For MI only, or minimal to no family involvement Variably or by individual clinical judgment Consultant or collaborative agreement with therapist for SA and MH onsite group Generic group on site for families on SA and MH issues, variably offered by staff member. Routine COD family group integrated into standard program format by staff member. Are family members provided information on how SA impacts an MI and vice cersa? What kind of supposrt is available for families on these issues? What happens if the client refuses to involve his/her family What would you do if the client is willing to involve his/her family, but the family refuses to participate in family treatment? Do you attempt outreach to the families? 8

9 IVI. Specialized interventions to facilitate use of COD self-help groups. Not present. Used variably by individual clinicians. Present, generic format on site. Specific to need of COD groups, special programs on site. In facilitating the connection to self-help groups, how are SA disorders considered? Are specialized introductions available? (i.e., a person diagnosed with social phobia is accompanied to group by someone and given special introduction) IVJ. Peer recovery supports for patients with CODs. Not present, not recommended. Off site, recommended variably Present, off site and facilitated with contact persons Off site, integrated into plan. Present, on site, facilitated and integrated into program (e.g. alumni groups) Are peer supports and role models available for clients with co-occurring SA and MI disorders? If so, are they on or off site, integrated with programming? V. CONTINUITY OF CARE VA. Co-occurring disorder addressed in discharge planning process. Not addressed Variably addressed by individual clinicians. COD systematically addressed as secondary in planning process for off site referral Both disorders seen as primary, and plans made and insured, on site, or by arrangement - off site. Is recovery from both MI and SA considered when developing a discharge plan? What types of services are people referred to? Are referrals followed up on? 9

10 VB. Capacity to maintain treatment continuity. Referral for SA treatments off site upon discharge (don t address at all until dc) Variably addressed by individual clinicians Documented monitoring of SA How is treatment for other disorder terminated or continued? Is this equivalent for both SA and MI disorders? Monitoring and ongoing treatment of SA VC. Focus on ongoing recovery issues for No Individual clinician determined. Primary MH, SA as potential relapse issue only. Focus on recovery from both disorders, both primary and ongoing. both disorders. Are the disorders seen as acute or chronic, short-term or long-term, primary or secondary? How is recovery envisioned and planned? Do clients have written recovery plans? (Recovery self-management instructions-non-professional planning) VD. Facilitation of self-help support groups for COD is No Rarely, but addressed by individual clinicians Yes, variably but not routine or systematic Yes, routine and systematic documented. At discharge - Is the potential increased self-help linkage difficulty for the person with a SA disorder anticipated and planned for? How is it dealt with? 10

11 VE. Sufficient supply and compliance plan for medications is No medications in plan. Yes, 30-day or supply to next appointment offsite. documented. How is the need for continued prescribing of SA-related meds dealt with? VI. STAFFING VIA. Psychiatrist or other physician. No formal relationship with program. Consultant or contractor off site. Consultant or contractor for on site. Staff member, present on site for clinical matters only What is the relationship with a psychiatrist, physician, or nurse practitioner (or other licensed prescribers)? VIB. On site staff with SA certification or No formal relationship with program. Less than 25% of staff members are. At least 25% of staff members are. expertise. Are any staff licensed, certified, or competent to provide SA services? How often does the SA counselor attend team meetings? How often does the SA counselor have contact with the client s CM in a typical week? Is the SA specialist considered a member of the team? How so? Do they carry a caseload? Are they involved in treatment planning Maintains medication management in program with provider after d/c. Staff member, present on site for clinical, supervision, treatment team, and/or administration. At least 50% of staff members are. 11

12 VIC. Access to SA supervision or consultation. No Yes, off site by consultant, undocumented. Yes, on site, documented PRN. Yes, on site undocumented regular supervision sessions. What is the arrangement for SA supervision and/or consultation for non-licensed staff? VID. Supervision, case management or utilization review procedures emphasize and support COD No Variable, by off site consultant, undocumented. Yes, on site, documented PRN and with COD issues. treatment. Is there a protocol to review the progress or process of treatments for SA disorders? Does the SA person talk about/cover COD? VIE. Peer/Alumni supports are available No Present, but as part of community. with COD. Are role models available for persons with co-occurring SA and MI disorders? Yes, on site, documented regular supervision sessions for clinical matters. Yes. Documented, routine and systematic coverage of COD issues. Present, on site. 12

13 VII. TRAINING VIIA. Basic training in prevalence, common signs & symptoms, screening and assessment for SA symptoms and Not trained in basic skills. Variably trained, not documented as part of systematic training plan, but encouraged by management. Trained in basic skills per agency strategic training plan. disorders. Who has basic training in screening and assessment? Who should have these basic skills? Is training documented? Trained in these skills per agency strategic training plan, and also have some specialized training in treatment approaches Trained in these skills per agency strategic training plan, and also have staff trained in specialized treatment approaches as part of plan. VIIB. Staff are crosstrained in mental health and substance use disorders, including Not trained, or not documented. Less than 33% trained. At least 50% trained At least 75% are trained At least 90% are trained. pharmacotherapies. (advanced cross-training including behavioral treatment) Who is trained? Who should be trained? Is staff training guided and monitored? ADDITIONAL SITE VISIT NOTES: 13

14 DUAL DIAGNOSIS CAPABILITY IN ADDICTION TREATMENT (DDCAT) FOR MENTAL HEALTH PROGRAM SUMMARY SCORE SHEET (VERSION 2.4) Program: Date of Review: Level of care: Reviewer(s): I. Program Structure A. B. C. D. Sum Total = /4 = SCORE II. Program Milieu A. B. Sum Total = /2 = SCORE III. Clinical Process: Assessment A. B. C. D. E. F. G. Sum Total = /7 = SCORE IV. Clinical Process: Treatment A. B. C. D. E. F. G. H. I. J. Sum Total = /10 = SCORE OVERALL SCORE (Sum of Scale Scores/7): DUAL DIAGNOSIS CAPABILITY: MHOS (1-1.99) MHOS/DDC (2-2.99) DDC (3-3.49) DDC/DDE ( ) DDE ( ) % CRITERIA MET FOR MHOS (# of 1 scores/35): % CRITERIA MET FOR DDC (# of 3 or < scores/35): % CRITERIA MET FOR DDE (# of 5 scores/35): HIGHEST LEVEL OF DD CAPABILITY (80% or more): V. Continuity of Care A. B. C. D. E. Sum Total = /5 = SCORE VI. Staffing A. B. C. D. E. Sum Total = /5 = SCORE VII. Training A. B. Sum Total = /2 = SCORE 14

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