Protocol to Support Individuals with a Dual Diagnosis in Central Alberta

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1 Protocol to Support Individuals with a Dual Diagnosis in Central Alberta Partners David Thompson Health Region Canadian Mental Health Association, Central Alberta Region Persons with Developmental Disabilities Central Alberta Community Board East Central Health Region # 5 Canadian Mental Health Association, East Central Region March 29, 2005 Revised March 20, 2006 Revised May 17, 2007

2 Table of Contents Introduction 3 The Partners 3 Principles for the Partnership 4 Commitment of Partners 5 The Protocol.. 6 Purpose 6 Scope 6 Description / Process 6 Leadership.. 7 Implementation.. 7 Coordination: Operational Lead... 7 Inventory of Resources 7 Education / Training / Communication. 7 Planning for Individuals who could be In Crisis 8 Planning for Individuals who are In Crisis... 8 Accountability 8 Evaluation 8 Protocol Approvals.. 9 Appendix 1: Dual Diagnosis Partnership Council of Central Alberta: Terms of Reference Highlights 11 Appendix 2: Description of Partner Organizations 12 Appendix 3: Responsibilities of the Operational Lead 17 Appendix 4: Elements of Success 18 2

3 Introduction Individuals who have both a developmental disability and significant mental health problems often have complex and highly challenging issues. For these people, effective support requires collaboration among multiple organizations, the individual and his/her support network. Effective support may also require the development of strategies that are a stretch from traditional practices and perhaps even from current policy. This Protocol has been developed by the Central Region Dual Diagnosis Partnership Council 1 as a way to increase the effectiveness of the supports provided. It has been developed to bring the stakeholders together, to confirm their commitment to collaboratively supporting individuals with a dual diagnosis, and to outline a framework in which this commitment can be enacted. The Partners The Partners who have developed this Protocol are: The David Thompson Health Region (DTHR) The Persons with Developmental Disabilities Central Alberta Community Board (PDD) The Canadian Mental Health Association, Central Alberta Region (CMHA) The Canadian Mental Health Association, East Central Health (CMHA) East Central Health Region # 5 An organizational description of each Partner is shown in Appendix 2. The Partners recognize that there are others who serve individuals with complex needs and that further work to explore the feasibility of expanding this Protocol to include other Partners, such as Human Resources and Employment, Children s Services, Home Care, Public Guardian, Brain Injury Societies, AISH, and the City of Red Deer could create additional benefits for individuals. The Partners also want to listen directly to the voices of individuals with a dual diagnosis, their families, and their support networks, and will build these opportunities into the implementation of this Protocol (e.g., see Appendix 3). 1 See Appendix 1 for the Terms of Reference of the Dual Diagnosis Partnership Council of Central Alberta. 3

4 Principles for the Partnership The Central Alberta Partners endorse these Principles to guide work undertaken through this Protocol: Appreciation of Diversity Each Partner will appreciate the diversity of skills, perspectives, experience and knowledge brought to the partnership by the other. A partnership combines this diversity in a way that enables the partnership to think in new and better ways about how to serve the community better. Valuing Relationship Fundamental to the partnership success is the encouragement of relationships among leaders and staff in the partner organizations. Relationship building opportunities are actively pursued among the partner organizations at all levels. Value Created Partners do more than exchange resources they create something new and valuable. This partnership will create value in that individuals will be served better across organizations. Investment Partnerships are relationships built over time and with shared experience. Partners show tangible signs of long-term and ongoing commitment by devoting resources to the relationship. Integrity Partners behave toward each other in ways that justify and enhance mutual trust. Decisions will be made with the input of all Partners that will allow for compromise and consensus. Each Partner has influence. Communication is open and constructive. Collaboration Inter-organization collaboration is aimed at producing and measuring better outcomes for people who use the services. Excellence All Partners are strong and have something valuable to contribute. The motives for entering into the partnership are positive and mutual benefits are sought for all Partners. 4

5 Commitment of Partners The Partners are committed to: never losing sight of the individual who needs support, as well as his/her social/support network having senior management allocate staff, budget and other resources as appropriate building commitment from staff throughout each Partner s organization using strategies that are based on current research and best practice for supporting individuals with a dual diagnoses taking risks and having the courage to go beyond and/or change existing policy and practice, where this is required to effectively support individuals being proactive in identifying issues before they become a crisis evaluating the effectiveness of this Protocol agreement to see if it is making a positive difference for individuals with a dual diagnosis viewing this as a long term relationship and to do whatever it takes to make the Partnership work 5

6 The Protocol The Protocol has been developed to document the spirit of collaboration that exists to support individuals with a dual diagnosis in Central Alberta. It is intended to inspire, support and guide staff from each partner organization as they fulfill their responsibilities toward the people they serve. The document is also intended to support and guide individuals who need these supports, their guardians and/or support networks (as appropriate), service providers, and any other interested individuals or organizations. Purpose The purposes of the Central Alberta Protocol are to: Support individuals with a dual diagnosis who have challenging and complex needs to live inclusive and quality lives Ensure that individuals who require support from all of the partnering organizations receive that assistance in a timely, effective and coordinated manner Encourage proactive, innovative, cross-boundary and collaborative working relationships among staff of partnering organizations Make the best use of resources for the well being of the individual who requires support Assure partners and stakeholders (including individuals, guardians, support networks, physicians, and service providers) that each representative from each partnering organization is committed to ensuring action occurs in response to a request for support Scope This Protocol will support individuals for whom all of the following statements apply: The individual has been determined to be eligible for support from both PDD and DTHR mental health or East Central Health Region # 5 community mental health The individual requires support from two or more of the partner organizations Supports or services required are available within the mandates of the partner organizations. 6

7 Description / Process of Protocol Leadership The Executive Director, Mental Health Services, DTHR, the Executive Director of CMHA, the Regional Mental Health Manager of East Central Health and the CEO of the PDD Central Board will meet at least once a year to reaffirm their commitment to the Protocol, provide future direction and to discuss any other issues that may arise. If trends emerge showing difficulty in responding to the needs of some individuals, Partners will develop strategies to increase community capacity to support people effectively. Coordination: Operational Lead Each Partner will identify an operational lead staff (the Lead), who will be the primary contact for his/her organization for purposes of the Protocol and who will have authority to act on behalf of his/her organization. He/she will ensure timely response to requests from a Partner or stakeholder and will facilitate implementation of the Protocol in a variety of ways. A more detailed description of the Lead s responsibilities can be found in Appendix 3). Education / Training / Communication Partners recognize the essential role of education and training in order to effectively support individuals. They will work collaboratively to ensure that relevant and timely training is available and targeted to a number of audiences including: Unique, specialized training for staff and others who directly support an individual; this will be specifically targeted to the unique issues (diagnosis, strategies, etc.) of that particular individual General training / education sessions for stakeholders including: o increasing awareness about issues related to individuals with a dual diagnosis o encouraging service providers to support individuals with a dual diagnosis and providing information about how they might do so o success stories Communication pertaining to the Protocol will occur through a variety of mechanisms including: the Dual Diagnosis Council; each partnering organization, and through the Operational Leads. Planning for Individuals who could be In Crisis 1. Each Partner will identify individuals of whom they are aware for whom the Protocol might apply. Summary information, which does not identify individuals, may be shared with other Partners, if beneficial. - 7

8 2. Each Partner will assess the ongoing stability and quality of the supports that are currently in place for each individual who they have identified. 3. If supports are not deemed to be sufficient, each Partner will implement strategies to address this, working with other Partners as needed. Strategies will be individualized, depending on the unique issues for each person. Staff will be encouraged and expected to work collaboratively and creatively to ensure that the individual receives effective supports. New individuals requesting service will also be supported using this approach. Planning for Individuals who are In Crisis If an individual can not be supported effectively, then a request for assistance can be made to the Lead of the relevant (or any) partnering organization. This request could come from the individual, his/her guardian, family and/or support network, service provider staff, and/or staff from DTHR, CMHA, PDD or East Central Health community mental health services. The Lead receiving the request is responsible to initiate the development of an effective option for the individual who requires support. This will be decided through a team approach, which includes the Lead(s) from other partner organization(s). Responsibility for finding an appropriate solution will be mutually assumed by each Partner. Responsibility for coordination will be determined among the participating Leads. Generally this will be the responsibility of the Lead from the Partner who will have primary responsibility for that individual. The coordinating Lead will ensure that action occurs and accountability is maintained. Accountability Each of the Partners is accountable to their own organization for implementing the Protocol. The Central Region Dual Diagnosis Council will have a standing agenda item for an update on the Protocol at each meeting. This will be another forum to discuss issues that may arise. Evaluation An evaluation process and implementation plan will be developed within a year of the signing of the Protocol. 8

9 Protocol Approvals This agreement, to support individuals with a dual diagnosis in Central Alberta, is entered into by the following Partners, starting April 1, It will be reviewed annually, and more frequently as required, at the request of any Partner. Partners David Thompson Health Region Rick Love Executive Director, Mental Health Services, DTHR Signature: Date: Canadian Mental Health Association Patricia Turnbull Executive Director Canadian Mental Health Association, Central Alberta Region Signature: Date: Persons with Developmental Disabilities Central Alberta Community Board Lorne McEwen Chief Operating Officer Persons with Developmental Disabilities Central Alberta Community Board Signature: Date: 9

10 Brenda Nelson Regional Mental Health Manager East Central Health Region # 5 Community Mental Health Services Signature: Date: Colleen Vennard Executive Director Canadian Mental Health Association, East Central Signature: Date: 10

11 Appendix 1: Dual Diagnosis Partnership Council of Central Alberta: Terms of Reference Highlights TERMS OF REFERENCE Highlights Dual Diagnosis (Developmental Disability and Mental Health) Partnership Council of Central Alberta Purpose To coordinate, collaborate, and plan resources and services that support and strengthen quality of life opportunities for individuals with a dual diagnosis. Principles Leadership, Action, Partnerships, Collaboration, Quality of Service, Person Centered Objectives increase awareness, education and shared training opportunities for service providers and caregivers improve planning and sharing of resources and responsibilities amongst service providers and funding organizations advocate for a full range of support services for people with a dual diagnosis. promote inclusion promote best practices and efficient resource utilization. identify and act to address current and future needs and issues relating to service for people with a dual diagnosis Membership Individuals and organizations of Central Alberta committed to supporting and enhancing services and supports for people with a dual diagnosis including, but not limited to: David Thompson Health Region Persons with Developmental Disabilities Central Alberta Region Office of the Public Guardian East Central Health Region # 5/Calgary Region Cosmos Rehabilitation Society Canadian Mental Health Association Employment Placement and Support Services Catholic Social Services Olds Association for Community Living Psychiatric Consultation Other individuals or organizations interested in participating 11

12 Appendix 2: Description of Partner Organizations David Thompson Health Region (DTHR) Mental Health Services DTHR Mental Health Services offers a range of mental health services in both community and hospital settings, including patient services at Red Deer Regional Hospital Centre and Centennial Centre. Programs offered are: Access and Early Intervention Access and Early Intervention provides an array of crisis and intake services throughout much of the region. Adult Inpatient This program provides specialized inpatient psychiatric assessment, treatment, and stabilization of acute psychiatric symptoms and long-term treatment and support recurrences of illness and recovery. Child & Adolescent Services are directed those aged 17 and under experiencing moderate to severe mental health difficulties. Adult Community The Adult Community Program provides a range of Adult Short Term and Assertive Outreach services throughout the region, to those who are predominately 18 years of age or older. Seniors Services include the: Inpatient Program; Community Services; Seniors Outreach Nurses; Psychiatric Consultation; Capacity Clinic; and Counseling. Brain Injury Rehabilitation This program has four service components: Inpatient Rehabilitation; Outpatient Clinic; Community Geographic Team; and the Brain Injury Curriculum. Canadian Mental Health Association (CMHA), Central Alberta Region Vision MENTAL HEALTH: ONE STEP AT A TIME. Mission The Canadian Mental Health Association is a non-profit organization promoting mental health and supporting people with mental illness. Based on community needs, staff and volunteers accomplish this through support, education, advocacy and community partnerships. 12

13 Service Delivery Canadian Mental Health Association has been providing programs and services in Central Alberta since Many of the services provided are delivered in partnership with other organizations. Education The agency provides education on mental illness and mental health issues for both the public and professionals. Mental Health Matters are noon hour educational sessions that are planned for professionals. Brochures, videos, and other materials are also available. Bereavement Bereavement counseling is available as well as grief recovery groups. The Bereavement Coordinator also provides training for professionals and the public. Guardianship Support Program The agency provides self help kits and assistance for individuals applying for guardianship or renewing a guardianship order. Coordinated Community Outreach Services In partnership with the Central Alberta Housing Society, Central Alberta Women s Outreach, and Red Deer Native Friendship Society, the agency provides outreach services to individuals who are homeless, facing a housing emergency, or requiring support to maintain housing. This assistance is provided when individuals do not meet the mandate for support from other organizations. Five outreach team members are employed through this partnership. Bridging and Loan Fund and Emergency Housing Funds are managed by the Coordinated Outreach Team administrators. The Bridging and Loan Fund provides interest free loans for security deposits and furniture and the emergency funds can be used to cover rental arrears, utility costs, or address other housing related emergencies. These funds do not need to be returned. Potter s Hands Housing The agency, David Thompson Health Region, mental health services and Potter s Hands Housing work in partnership to provide integrated housing with suites reserved for people with mental illness. Currently, 15 bachelor suites and 2, three bedroom apartments are reserved. DTHR, Assertive Outreach staff and the Coordinated Community Outreach Team jointly approve the acceptance of tenants. Services for Individuals with Acquired Brain Injury In partnership with Catholic Social Services, the agency provides support and coordination services for adults with acquired brain injury. The agency also contracts Supports for Community Living staff to provide one-to-one support for individuals up to ten hours per week. 13

14 Peer Support The peer support program is designed to assist and build the capacity of people with mental illness to help them help each other. The program provides an eight week Art of Friendship Course, supports the development of peer relationships, and provides peer mentorship opportunities. Volunteer Services The agency supports between volunteers annually. A volunteer manager is responsible for recruitment, training, evaluation, and recognition of the volunteers contributions. Persons with Developmental Disabilities (PDD) Central Alberta Community Board The PDD Central Alberta Community Board was established in 1998 in order to support adults with developmental disabilities in this region. The Board s vision is: Persons with developmental disabilities are welcomed, respected and valued members of our communities. The Mission of the Central Board is: We ensure individuals with developmental disabilities and their families have support, opportunities and choices to lead full and inclusive lives in our communities. The PDD Central Alberta Community Board offers a flexible array of supports and funding within the following broad categories to approximately 1800 individuals: Community Living Supports provide flexible home supports, including overnight staffed homes, support homes, supported independent living and respite support. Employment Supports assist the person to gain and maintain employment. The two components within the category are Employment Preparation and Employment Placement supports. Community Connection Supports promote a person s relationships with others in their community through participation in community activities and personal development. These are an alternative or supplement to employment. Specialized Supports provide unique supports as required to assist the person in his/her environment or to enhance connections within his/her community. These include: social skills training, specialized counseling, advocacy and behavioral supports. These supports are provided to individuals living within Central Alberta through a network of community service providers and through direct services at Michener Services and Youngstown Home. 14

15 The range and extent of supports provided varies widely, based on the unique needs of the individual. The focus is not on providing programs, but on supporting individuals to participate in and be included in their community. East Central Health Region #5 (ECH) Community Mental Health Services ECH community mental health offers a range of mental health services within the community. Program offered are as follows: Child and Adolescent Team Services are available to children/adolescents under the age of 18 and their families who are experiencing emotional problems that have a substantial impact on their lives. Adult Team Community clinic provide a variety of assessment, treatment and consultation services to individuals between the ages of Seniors Team Services are provided to individuals generally over the age of 65 years who present with complex mental health disorders and who may experience cognitive, behavioral, and/or functional changes. Brain Injury Program The Brain injury rehabilitation program includes the following specialized services for persons affected by an acquired brain injury: education; inpatient rehabilitation; outpatient clinics. Prevention and Promotion program The program primarily promotes mental health promotion activities through the coordination of various partners throughout the region; will enhance mental health and emotional wellness through educational initiatives; assist with the assessment of community and consumers needs. Canadian Mental Health Association (CMHA), East Central Region Vision MENTAL HEALTH: ONE STEP AT A TIME. Mission The Canadian Mental Health Association is a non-profit volunteer organization that strives to ensure the best possible care, treatment and quality of life for individuals with mental illness, and seeks to promote mental health for all people. 15

16 Service Delivery Canadian Mental Health Association, East Central Health has been providing programs and services in East Central Alberta since Many of the services provided are delivered in partnership with other organizations Resource Centre The Resource Centre provides drop-in activities and support. Individual Supports Program This programs objective is assist individuals with dual diagnoses live independently and interdependently in the community. Education These include presentations and print materials. A consumer sponsored speaker s group educates the public about severe and persistent mental illness from a personal perspective. We also train interested consumers in the basic cooking skills which includes understanding nutritional values, preparing simple meals and provision of a community kitchen. Employment We also provide employment support services to individuals who have a mental illness or a developmental disability and want to be employed. This program will work with these individuals to assess and build on their abilities. Acquired Brain Injury The agency provides support and coordination services, as well as one-to-one support for individuals. Residential Housing We provide housing for individuals. Staff is provided through our Independent Living Skills Program. Assertive Outreach Services Provides support to people who are in the greatest need, who might not otherwise be reached by more typical human service efforts. Independent Living supports Program To assist individuals with severe and persistent mental illness live independently and interdependently in the community. 16

17 Appendix 3: Responsibilities of the Operational Lead Each Partner will identify an operational lead staff (the Lead), who will be the primary contact for his/her organization for purposes of the Protocol. The responsibilities of each Lead include: Ensuring that staff within his/her own organization understand the philosophy and principles of, and can implement, the Protocol process o Strategies might include training, information sessions, developing resource material, joint training with other Leads, etc. Where existing processes/resources are not adequately supporting an individual, working with the Lead from the relevant partnering organization(s) to ensure that the individual receives the support he/she needs in a seamless and timely manner o As needed, this could include: accessing required services within his/her own organization; case coordination; and follow up Ensuring that the approaches used to support individuals are based on current research and best practice In collaboration with the other Leads, gathering data on the how the Protocol is being utilized In collaboration with the other Leads, developing an evaluation process to measure the effectiveness of the Protocol Developing and maintaining ongoing positive, collaborative and professional relationships with each partnering organization In collaboration with the other Leads, the Lead of PDD, Central Region Community Board will be the initial contact for admissions to the Centennial Centre and RDRHC (for individuals with a Dual Diagnosis). This will enable planning for discharge to take place at the time of admission. Contact will be made to the Lead, from the Social Work Department of the Centennial Centre and the RDRHC. The Lead will be responsible to interface with the PDD Complex Needs Assessment and Service Integration Team Protocol. 17

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