Ivy F. Scholfield, M.S.C.J. Criminogenic Needs Specialist

Transcription

1 Dunn County Criminal Justice System & Behavioral Health Providers: A Roadmap to Improve Services and Outcomes for Individuals with Co-Occurring Disorders Recommendations for an Evidencebased Treatment Protocol for Criminal Justice Participants Who Present with Co-Occurring Mental Health and Substance Use Disorders and Discussion of the Employer/Community Service Sites Needs/Criminal Justice Participants Skills Match Database Project Ivy F. Scholfield, M.S.C.J. Criminogenic Needs Specialist In Consultation with the Dunn County Criminal Justice Collaboration Council, and Julienne Giard, M.S.W., Co-Occurring Disorders and Evidence-based Practices Consultant May 2012

2 The Dunn County Evidence-based Treatment Protocol and Employment Project was made possible by the Wisconsin Office of Justice Assistance, Grant No DJ Award Date 5/17/2011 and End Date 5/31/2012

3 TABLE OF CONTENTS Executive Summary 1 Acknowledgements. 6 Introduction. 7 Project Goals 10 Methodology. 11 Literature Review. 13 Findings: Evaluation of Community Treatment Resources in Dunn County and Information Gathered from Gaps Analysis and Cross System Analysis. 15 Recommendations/Components Screening and Assessments Integrated Services 24 -Database of Evidence-based and Best Practices Treatment Protocol Employment Services. 30 -Other Considerations Trauma-specific Interventions/Gender-based Programming. 32 a. Trauma-informed Care b. Trauma-specific Services 6. Quality Assurance.. 34 a. Client-level Data Collection Tool b. Aggregate Client-level Data Collection Tool c. Program-level Data Collection Tool 7. Additional Considerations.. 37 a. Continuity of Care b. Treatment Appointment Availability c. Medication Management d. Funding for Services e. Collaboration Conclusion. 39 References.. 43 Appendix: Attachment A: Agencies Interviewed 47

4 Attachment B: Database of Evidence-based Practices/Best Practices.. 48 Attachment C: Reference Chart of Disorders and Evidence-based Treatments (Children and Adolescents) 58 Attachment D: Co-occurring Definition; Sample Report Template for Dunn County. 58 Attachment E: DDCAT Rating Scale. 98 Attachment F: DDCMHT Rating Scale..109 Attachment G: IDDT Integrated Treatment Fidelity Scale.122 Attachment H: Co-occurring Assessment Guidelines. 132 Attachment I: Integrated Treatment Curricula 137 Attachment J: Employment Workshop/Database Document..138 Attachment K: Supported Employment Fidelity Scale 140 Attachment L: Co-occurring Disorders PowerPoint 158

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6 Executive Summary Evidence-Based Practices (EBP) and Co-occurring Disorders (COD) Treatment Protocol Across the four main behavioral health providers in Dunn County there exist several evidencebased practices, or components of them, given the review of their policies and procedures and key informant interview data. Overall, it is recommended that a system of care, whether that be a state or a sub-state region, such as a county, include the following 22 evidence-based and best practices. The term best practices is used here as well because some of these are not considered full-fledged evidence-based practices, but there is consensus in the field that they are important and evidence for their effectiveness is building. As a back-drop to all services, the following practices should be across all services: Gender Responsive Services Person-Centered Recovery Planning Recovery-Oriented Care Trauma-Informed Care The other 18 practices could be offered at one or more locations: Assertive Community Treatment (ACT) Cognitive Behavioral Therapy (CBT) Consumer-Operated Services Dialectical Behavior Therapy (DBT) Diversion & Re-Entry Services Dual Diagnosis Capability in Addiction Treatment (DDCAT) Eye Movement Desensitization & Reprocessing (EMDR) Family Psychoeducation Illness Management & Recovery (IMR) Integrated Dual Disorders Treatment (IDDT) or Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Medication Assisted Treatment (MAT) Motivational Interviewing (MI) Psychiatric Rehabilitation Supported Employment Supportive Housing Trauma-Specific Services 12-Step Facilitation There may even be additional practices that some might add to this list or configure it in different ways. For example, EMDR might be included in the category of trauma-specific services. Some of the practices are embedded in others (e.g., MI, CBT, 12-step facilitation in DDCAT, IDDT). Some of these are targeted individual-level practices (e.g., MAT, Psychiatric Rehabilitation), some are team-based approaches (e.g., ACT), and some are program-level models (e.g., DDCAT, IDDT). Some of the practices would be hosted or provided by agencies that are more 1

7 traditionally mental health providers and some would be provided by programs that are more traditionally addiction treatment providers. The seven evidence-based practices (EBPs) specifically endorsed and disseminated by the Center for Mental Health Services (CMHS) at the federal Substance Abuse and Mental Health Services Administration (SAMHSA) include: ACT, Consumer-Operated Services, Family Psychoeducation, IDDT, IMR, Supported Employment, and Supportive Housing. In general, this is a good overall list to use to evaluate the adequacy of your system and to use as a planning tool to the extent that some of these services don t exist at all or in limited amounts. The associated EBP database includes a brief definition of each of these practices, including a link to one or more websites, the diagnoses the practice would be used for, and the stages of change that the practice would be used for. In terms of individuals with co-occurring mental health and substance use disorders (COD), some of the practices in the list on page one are key: DDCAT/DDCMHT and IDDT. And within these program-level models, several other EBPs are included: CBT, DBT, EMDR, Family Psychoeducation, MAT, MI, Trauma-specific services, and 12-step facilitation. In terms of one or more specific treatment protocols for individuals with COD, it is important to remember that the population of individuals with COD is not homogenous; there are at least four subpopulations (i.e., the quadrant model). The goal is to provide integrated treatment for all of these groups. Integrated treatment is defined as one recovery plan including concurrent services for both mental health and substance use disorders, provided ideally by one clinician, team or program. Integrated treatment can occur across programs, but it is more difficult to truly achieve integration this way. In general, mental health programs can be designated to provide integrated treatment for individuals in quadrants II and IV (i.e., persons with severe mental illnesses and co-occurring substance abuse or dependence disorders). The IDDT or DDCMHT models/fidelity scale guides program development in these programs. Addiction treatment programs can be designated to provide integrated treatment for individuals in quadrant III (i.e., persons with low-moderate mental illnesses and co-occurring substance dependence disorders). The DDCAT model/fidelity scale guides program development in these programs. The seven domains of the DDCAT (and DDCMHT) are a helpful framework for assessing and developing integrated treatment programs and are as follows: program structure, milieu, assessment, treatment, continuity of care, staffing, and training. To take the treatment protocol concept a step further, the following specific interventions and the sequencing of them provides good core steps. The following steps could be used for individuals in jail treatment programs or community-based programs in general: 1) Administration of standardized/validated mental health and substance use screening measures (e.g., Modified Mini, SSI-AOD); a. Additional specific screening measures could be administered based on results of these initial general screens (e.g., trauma-specific screen); 2

8 2) For individuals scoring positive on both screens, a comprehensive, integrated and longitudinal assessment (Attachment H) should include assessment of individual s stage of change for each mental health and substance use disorder; 3) Diagnosis and documentation of all mental health and substance use disorders; 4) Development of a person-centered recovery plan that includes stage-based objectives and interventions related to both mental health and substance use disorders; 5) Interventions likely to include a combination of the following for many individuals with co-occurring disorders, in either mental health or addiction treatment programs: a. MI b. Co-Occurring education group (e.g., USF free-downloadable curriculum) c. Co-Occurring Treatment group (e.g., Hazelden Co-Occurring Disorders Program Module 2: MI, CBT, 12-step facilitation) d. Trauma-specific groups (e.g., Seeking Safety, Trauma Recovery and Empowerment (TREM) for both men and women) e. Medications for psychiatric and substance use disorders f. Family education regarding COD and involvement in recovery plan g. Peer support groups welcoming to individuals with COD or specific to COD (e.g., Double Trouble in Recovery) h. Peers with COD as sponsors or speakers Factors important to the development of the above protocols include a focus on workforce development, including training, competent and frequent supervision of direct care staff, program fidelity reviews and feedback, and use of data to inform program development. The four main providers in Dunn County appear to have at least some of these EBPs and protocols. For many of the EBPs it is not a yes or no question and answer whether the EBP exists or not; the practices exist on a continuum, from poorly implemented to fully implemented. Fidelity reviews for the different EBPs conducted in each program would yield more specific and comprehensive information about the current co-occurring capability of each program and the extent to which the different EBPs exist. Based on review of policies, procedures and interview data, and the focus group of providers, some EBPs from the list on page one already exist in the County to at least some degree in one or more locations. Again, fidelity reviews have not been completed. The existing EBPs are as follows: CBT (Arbor, DHS) DBT (Arbor) Diversion/Re-entry Family Psychoeducation (Arbor) MAT (DHS, Mayo) MI (Arbor) Psychiatric Rehabilitation (Aurora - CSP) 12-Step Facilitation (Arbor) Gender-specific/responsive programming (Arbor) 3

9 Recovery-Oriented Care (Arbor) Supported Employment (Aurora) Trauma-Specific Service (Arbor) It is suspected that all agencies are doing some level of MI, CBT, Family Psychoeducation, 12- step facilitation, recovery-oriented care and trauma services, but they may not be listed in their policies and procedures or specifically noted in the interview data. On-site reviews are the best method of determining if practices are present and to what degree. Consensus on thresholds for considering a practice implemented or not is important. The practices missing from the service system include the following: ACT COS DDCAT IMR IDDT/DDCMHT Person-Centered Recovery Planning Supportive Housing Trauma-informed Care In terms of the core components listed in the section above, specific to co-occurring disorders, onsite reviews are required to determine the extent to which these are currently present at each agency/program. There can be variation across agencies, but also across programs within agencies. Employers /Community Service Sites Needs/Criminal Justice Participants Skills Match Database Project Within Dunn County, exist several agencies that provide employment services, with some of these programs providing vocational services to criminal justice participants. However, no one agency has been identified as having established a protocol to match clients skills with employer and community service sites needs, especially for those clients in the criminal justice system. The goal is to connect clients with employers and community service sites prior to and upon reentry into the community. This outcome has the potential to build a bridge between clients and the community by dispelling myths and eradicating stigmas that have only stood to serve as barriers between clients and their successful reintegration into society. By providing education to the community concerning the benefits and importance of hiring criminal justice participants and implementing a working protocol to match client s skills with employers and community service sites need, clients will have a better chance of securing and sustaining employment. This action plan could lead to a decrease in recidivism rates and an increase in community safety. It could also help decrease the use of tax dollars in this area and free up finances to be used in other, yet equally important, areas. Overall, it is recommended that the county do the following: Continue to educate employers and the community as a whole regarding the benefits and importance of hiring criminal justice participants. Education can be provided through a 4

10 number of channels, such as annual employment workshops, Criminal Justice Collaboration Council bimonthly meetings, and community presentations done on an individual or community-wide basis. Ideally, the plan would be to have the Skills/Needs Match Coordinator connect with the employers and community service sites within Dunn County and keep them informed, interested, and invested in the project. Continue to develop the employment database, housed on the CJCC website, which will serve as a meeting place to match clients skills with employers needs. By creating a database of employers currently willing and ready to hire participants, one less barrier will exist. Clients will know what employers are on board and where they can put their skills to work. Continue to attend bimonthly CJCC meetings to remain updated on collaboration efforts in this area and to become involved in the mission through networking and taking information learned back into the community or specifically to other potential employers/community service sites. CJCC attendees can also pledge to invite employers to the meetings to help build on the team s efforts. Also, since much work is already taking place in the area of vocational services, it is suggested that agencies/groups make an effort to collaborate and to consider hiring and retaining participants as a community effort. Continue to educate community service sites about the benefits of hosting criminal justice clients within their establishments and to build upon the current community service site list, made available to support staff, clients in the jail, and those in the general population. After all, community service work enhances pro-social behaviors and skills and gives both clients and sites a chance to connect for the greater good. It is also possible that after clients have fulfilled their community service requirements, they will have an opportunity to be hired on or at least provided with a positive reference and referred on to another organization for paid hours. It appears that employment services and community service site projects are available in Dunn County but could be enhanced by implementing a protocol that combines an online needs/skills database, community education, and attendance at CJCC meetings for collaboration and networking purposes. In addition, it is suggested that the EBP Supported Employment, which helps people with mental illnesses (and co-occurring disorders) find and keep meaningful jobs in the community, is implemented within these services. 5

11 Acknowledgements This evaluation was made possible by the Office of Justice Assistance Grant. The authors would also like to thank all those who assisted with this project. Without their vision, assistance, and support, the completion of this project would not have been possible. 6

12 Introduction Navigating the criminal justice system can be daunting to anyone, especially for those criminal justice participants who are dealing with a mental health disorder coupled with a substance use disorder. The Council of State Governments Justice Center (n.d.) states the following: It is estimated that 75 percent of people with mental illness within the criminal justice system meet criteria for drug and/or alcohol abuse or dependence; some cite figures indicating that up to 90 percent of those behind bars with either mental illness or substance abuse disorders have co-occurring disorders (chapter 7, Policy Statement 37). Substance use and certain mental health disorders have been identified as two of the criminogenic needs, which are crime producing factors that are strongly correlated with risk (Latessa & Lowenkamp, n.d., Curriculum: 6 Criminogenic Needs/Factors section). These dualdiagnosed, misdiagnosed, or undiagnosed clients can find themselves struggling to meet the requirements or following through with recommendations of criminal justice staff due to several identified gaps and barriers in the existing treatment protocol. These gaps and barriers are as follows: lack of standardized screening measures, lack of integrated services, lack of supported employment, lack of trauma-informed/trauma-specific services, and lack of a data collection tool(s). Additionally, problems exist related to continuity of care, treatment appointment availability, medication management, funding for services, and collaboration among providers. Overall, problems in the system are not met with evidence-based solutions. As mentioned above, criminal justice participants may face huge obstacles prior to or upon re-entering society, such as the lack of supported employment. If individuals are unable to 7

13 obtain or sustain employment, they are more likely to be unsuccessful in their recovery and become productive members of society. Lack of employment has also been identified as one of the criminogenic needs (Latessa & Lowenkamp, n.d.). According to Finn (1998): Many offenders have difficulty finding permanent, unsubsidized, well-paid employment after release because they lack job-seeking experience, a work history, and occupational skills; furthermore, many employers refuse to hire individuals with criminal records. These circumstances seriously affect an ex-offender s stability because unemployment is consistently associated with high recidivism rates (para. 1). It makes no sense for participants to serve their time and then be released onto the streets without some ground to stand on. A large, three-state recidivism study found that less than half of released prisoners had secured a job upon their return to the community (Council of State Governments Justice Center, n.d., Reentry Facts section). Participants require many needs to be fulfilled if the goal is to keep them out of the system or prevent them from entering the system on an even deeper level. Employment is one of those needs. In fact, it has been reported that of those participants who have been successful in the Dunn County Diversion Court Program, all were employed at the time. It would appear that by fulfilling this particular criminogenic need, clients have a greater chance of achieving success in both recovery programs and in the community as a whole. If participants secure a position and retain that position, they are more apt to be successful in their recovery and not return to the system. To add to the problem, many of these clients have experienced trauma at some point in their lives and received little to no treatment for this. In fact, according to Harlow and 8

14 Kassebaum (1999), Individuals involved with the correctional system, especially female offenders, are particularly likely to have had trauma exposure (as cited in Giard, 2008, p.12). Also, Greenfeld and Snell (1999) state that in state prisons alone, 57% of the female population has reported physical and/or sexual abuse in their background (as cited in Giard, 2008, p.12). This is why it is very important to provide gender-responsive programming for both male and female clients. Moreover, it is thought that all related programming should be data driven and focused on meeting the criminogenic needs, thus decreasing the chances of recidivism. One unmet criminogenic need may not lead to re-arrest but multiple unmet needs can increase risks for recidivism (Latessa & Lowenkamp, n.d.). Appropriate programming will not change static factors (i.e. age, criminal history) but instead, help providers focus on dynamic factors that can lead to changes in clients values, attitudes, and behaviors (Latessa & Lowenkamp, n.d.). If programming includes components that address a minimum of four to six criminogenic needs, it can decrease recidivism rates by 30 percent (Latessa & Lowenkamp, n.d.). Therefore, clients who have multiple criminogenic needs, such as lack of employment and co-occurring mental health and substance use disorders, coupled with other various challenges, should have access to appropriate treatment providers and systems. Additionally, these clients should be supported by a collaborated effort to ensure continuity of care and longterm success in the community. This is also true for Dunn County. Therefore, results of this evaluation beg the question, What can the community do collaboratively to meet the multiple needs of criminal justice participants, while improving the system and community as a whole? 9

15 Project Goals The purpose of this evaluation was two-fold and therefore, had two requirements. First, through the Office of Justice Assistance Grant, awarded to the Dunn County Criminal Justice Collaboration Council (CJCC) in 2011, the requirement included the development of an evidence-based treatment protocol for criminal justice participants, juvenile and adult, who present with co-occurring mental health and substance use disorders. The second requirement included the development of a database to serve as a central location for matching clients skills with employers and community service sites needs, which will be housed on the CJCC website. The goal is to increase employment opportunities and retention among a population that is often overlooked or buried under myths and stigmatizations potentially leading to employment of participants prior to or upon re-entry. However, while increasing employment opportunities and employing more participants is a primary goal for this part of the project, enlisting additional community service sites to host participants is a secondary goal. Participants have an opportunity to give back to society and benefit immensely through community service. In fact, The intangible benefits alone such as pride, satisfaction and accomplishment are worthwhile reasons to serve. In addition, when we share our time and talents, we: solve problems, strengthen communities, improve lives, connect to others, transform our own lives (Corporation for National & Community Service, 2012, For Individuals section). Moreover, the purpose of this paper is to serve as a record of the evaluation and as a potential future guide for implementing an evidence-based protocol specific to this population. The goals for the paper are as follows: Demonstrate how common it is for co-occurring mental health and substance use disorders to exist within the criminal justice population. 10

16 Identify those problems that have prevented clients from receiving appropriate treatment and therefore, successful recoveries. Highlight the findings of an extensive review of Dunn County s primary providers policies and procedures to identify strengths and weaknesses in services and programming. Discuss employer needs/clients skills project results, to include outcome of community workshop and database to be housed on the Dunn County CJCC site. Make recommendations concerning a more effective treatment protocol specific to Dunn County and to discuss the importance of continuing to connect participants with employers and community service sites prior to and upon re-entry. The completion of this grant project could provide an effective working protocol, which could potentially fill in the current gaps in services and remove barriers that currently prevent COD clients from receiving appropriate treatment. Consequently, it is hoped that this protocol will decrease recidivism rates and increase community safety in Dunn County, eventually decreasing costs for the criminal justice system and the community as a whole. The treatment protocol will be based on services that are available in Dunn County. Methodology To complete part one of the OJA Grant Evaluation, several steps were taken in the data collection process. First, as part of phase one, available data was collected and empirical studies were reviewed from secondary sources. Interviews were conducted in-person and by phone with treatment providers, community agencies, and various stakeholders (Attachment A). In addition, observations were made during the day-to-day operations of diversion court treatment meetings. 11

17 Second, three surveys retrieved from a study by Watson, Maclaren, Shaw, and Nolan (2003) at were mailed to seven treatment providers. These were used to help determine staff s attitudes and perceptions regarding the use of EBP and the treatment of clients with co-occurring mental health and substance use disorders. Moreover, phase two included a comprehensive review of treatment providers policies and procedures. This information was requested from those Dunn County agencies that provide both types of treatment, which was narrowed down to four primary providers. These policies and procedures were then reviewed by both the Criminogenic Needs Specialist (CNS) and the Co- Occurring Disorders (COD) and Evidence-Based Practice (EBP) Consultant. The consultant provided expertise in both areas and worked with the CNS to develop a treatment protocol based on EBP for those clients who present with COD in the criminal justice system. In order to complete part two of the evaluation, Dunn County employers were contacted by phone to identify companies willing to attend an Employer/Criminal Justice Participant Skills-Need Match Workshop. Second, workshop invitations were mailed to those employers who were identified as having an interest or willingness in hiring criminal justice participants, as well as other various suitable companies. Third, a PowerPoint presentation demonstrating the importance and benefits of hiring CJP was created by Stepping Stones. Next, a Workforce Development representative from Madison, Wisconsin, was invited to present information regarding the Work Opportunity Tax Credit. However, since the credit has not yet been approved for 2012, the representative was unable to do a presentation but supplied a copy of the Department s PowerPoint presentation instead. In addition to these steps, the current community services site list was updated to reflect only those organizations that wish to remain on the

18 list. Also, a database form (Attachment J) was created and used at the completion of the workshop to identify those employers interested in hiring CJP and those willing to be included in the CJCC website database. Lastly, a workshop folder was created and dispensed as a resource for employers. The workshop was held February Literature Review Utilizing programs that are based on EBP is not a new concept. However, there is a new movement that is pushing more organizations to buckle down and review their policies and procedures due to significant gaps in their treatment protocol or programming, along with rising health care and criminal justice costs and empty pockets. More importantly, there has been a need to further evaluate treatment protocols and services for co-occurring substance use and mental health disorders and support these protocols with evidence-based practices, especially integrated services. In fact, movement is not only being made in the criminal justice system but in the health care system as well. Health care reform has the potential to better meet the needs of this population. Therefore, the Affordable Health Care Act, which is to be implemented in 2014, unless it is overturned, calls for integrating Mental Health and Substance Use and primary care. The more we can ensure these two areas are integrated now, the better off systems will be in 2014 to integrate primary care. A review of existing data and empirical studies on treating co-occurring substance use and mental health disorders demonstrates the need to reevaluate how treatment providers and criminal justice staff perceive or provide services to clients in the criminal justice system. Academic research has shown that 50 percent of people with severe mental illness are rearrested because they cannot follow through with probation and parole requirements due to factors related to their mental illness (NAMI, 2010). These clients are not re-arrested for re-offending, which 13

19 suggests that their mental health needs were not met (NAMI, 2010). If this issue is coupled with a substance use disorder, it can only exacerbate the problem and spell failure for many clients. In addition, in a recent study of all persons seeking alcohol or other drug treatment in Ontario, it was found that 65% had also had a psychiatric disorder (Ross et al, 1998) (Winnipeg Regional Health Authority & The Addictions Foundation of Manitoba, 2001, p. 1). The literature also indicates that a variety of barriers prevent clients with co-occurring disorders from receiving appropriate treatment, such as clinicians in both fields viewing them as difficult clients (WRHA & AFM, 2001). Moreover, these disorders have been typically been treated separately in two different systems. According to WRHA and AFM (2001), the system barriers are as follows: Most traditional mental health and substance abuse programs typically are not designed to accommodate dual disorder clients Propensity for clinicians to view dual disorder clients as the responsibility of the alternate service field Lack of specialized services and cross-trained clinicians Lack of shared case management, shared tools, and assessment language between the fields Fundamentally different perspectives on the nature and origin of the problems experienced by the client and different perspectives on what constitutes appropriate treatment responses Organizational funding and governance barriers to cooperative and collaborative program development (p. 3) Over the last 20 years, several goals have been identified while conducting research on COD, to include the following: the rate at which these two disorders occur together, how one of the disorders increases the chance of developing the other disorder, creating and testing many treatment models and ways in which to respond to clients with COD, researching how treatment 14

20 systems respond to COD, and examining novel treatment protocols, with a particular emphasis on integrated models of care, that seek to treat multiple needs related to mental health, substance use and abuse, behavioral problems, and health concerns (Sacks, Chandler, & Gonzales, 2008, introduction section 1.0). Findings: Evaluation of Community Treatment Resources in Dunn County and Information Gathered from Gaps Analysis and Cross System Analysis An extensive review of Dunn County s current treatment providers for substance use and mental health disorders reveals similar disparities to national and state findings. The findings from an evaluation of local treatment providers reflect similar gaps and barriers in service as state and national statistics. According to Wisconsin Mental Health State Plan ( ), Of 1,315 outpatient providers, only 294 are certified as both mental health and substance use providers (p. 82). Even though Dunn County is a small county with a population of 43, 857 (U.S. Census Bureau, 2011), of the four primary mental health and substance abuse treatment providers, no one agency or program has been solely identified as providing integrated mental health and substance use treatment. The evaluation of the four primary treatment providers policies and procedures helped in not only determining the location of gaps and barriers in the system but also helped shape and define the suggested protocol. Agency s policies and procedures were requested in writing in October While all of the P&Ps were eventually received, it is important to note that of Dunn County s four primary providers available to clients with mental health and substance use needs, only two provided their policies and procedures promptly, while the other two did so by the end of January This outcome and other data could be an indication that communication and collaboration efforts 15

21 in this area could be improved. The next section includes the findings following an extensive review of the four primary treatment providers policies and procedures. Key informant interview data and policies and procedures from the four main behavioral health providers in Dunn County were reviewed and evaluated. As mentioned earlier, the four providers are Arbor Place, Inc., Aurora Community Services, Dunn County Department of Human Services (DHS), and Mayo Clinic Behavioral Health. These data provide only a snapshot of information about policies and programming at these providers, but nevertheless provide some insight into strengths and gaps present in the county. Arbor Place, Inc. provides substance use and mental health treatment services for Dunn County criminal justice clients. Aurora (Access) is a human service agency that provides counseling and psychological assessments for Dunn County criminal justice clients within the jail. Their services include risk assessments for suicide prevention, AODA classes, and Anger Management classes within the jail. DHS is a county department that provides a variety of human services, to include Family and Children Services, Behavioral Health Services, Economic Support Services, and Aging and Disability Resources Services. The Department provides a wide variety of human services, which are primarily mandated by Federal and State statutes and rules. The Department s staff and services are funded through 80% Federal/State dollars and 20% County levy dollars (Dunn County Human Services, 2012, the Department provides section). Mayo Clinic Behavioral Health is a behavioral health department that provides counseling and psychological assessments and serves individuals on an inpatient, outpatient, and residential basis. 16

22 The findings from the review/evaluation of the interview data and policy and procedure review include the following observations: Overall, in terms of strengths, there appears to be widespread recognition of individuals with co-occurring disorders, their needs, and the current problems delivering/accessing integrated treatment. In addition, agencies do not appear to be limiting clients with co-occurring disorders to sequential treatment (i.e., we cannot provide you with mental health services until you complete addition treatment or we cannot provide you with addiction treatment until you complete mental health services ), which is a good thing. Many of the core service components of integrated treatment / programming appear to exist in the system at one or more locations. In terms of deficits, agencies appear to provide parallel mental health and addiction treatment to individuals with co-occurring disorders with no one agency or program identified as providing integrated treatment. In terms of service components, there was no mention of the evidence-based practice called Supported Employment for individuals with mental illnesses (and individuals with co-occurring disorders). Supported Employment helps people with mental illnesses (and co-occurring disorders) find and keep meaningful jobs in the community. Components of the model include consumer choice, integration of services, competitive jobs, benefits counseling, timely support, continuous services, and consumer preferences. Although Aurora Community Services reports supporting the Supported Employment Model, it is not sure whether it is supported by an evidence-based model. Moreover, several agencies provide employment services throughout the county but it is not sure whether they are utilizing the EBP, Supported Employment. Given the goals of this grant and its emphasis on employment, this would be an important service to implement and have available in the county s service array. There was no mention of trauma-informed care and trauma-specific interventions. Given the 17

23 very high percentage of women and men in criminal justice and treatment settings with histories of trauma, this would be an important area to explore. The service component of medication management is not available to the extent that it needs to be. Access to funding for medications is problematic, even if psychiatric time is available. In terms of staffing, there appears to be few, if any, dually licensed practitioners. However, there are licensed mental health practitioners and licensed/certified addiction treatment staff across the four agencies that can be used in coordinated ways to deliver integrated treatment. Integrated services could be provided by sharing staff across agencies to co facilitate COD groups. There are several specific findings in the Policies and Procedures for each of the agencies. Aurora Community Services policies and procedures reference use of an Intake Form: Mental Health and AODA, chart audits are done using a Mental Health Quality Assurance Checklist and AODA Quality Assurance Checklist, and supervision of staff includes an AODA Certified Clinical Supervisor and a M.D. with experience in addictions. These are all good components to support integrated treatment. However, while Aurora s policies and procedures specifically noted use of quality assurance checklists, Arbor Place and DHS s policies and procedures did not indicate use of similar checklists. Also, DHS s behavioral health policies and procedures do not mention integrated treatment. Arbor Place s orientation training for staff includes mental health and addiction treatment components. It appears the agency provides both mental health and addiction treatment, although it does not sound like these are provided as integrated treatment when needed. Mayo Behavioral Health Services policies and procedures refer to their use of the AUDIT-C screen for substance use problems, to facilitate referral processes, but were clear they do not provide addiction treatment. 18

24 Overall, the key elements of integrated treatment for individuals with co-occurring disorders are: Program structure, program milieu, assessment, treatment, continuity of care, staffing and training. The interview data and policies and procedures make mention of a few practices that appear to be happening that fall into these seven categories/elements, but the majority of the elements do not appear to exist in an integrated way. Gender-responsive programming is also very important, as is integrated services for individuals with co-occurring disorders. This programming was not evident in the findings. While some offer gender-based classes, it does not seem to be a significant component within these agencies. In order to better understand gender-responsive services, see attached EBP database and the link to gender responsive guidelines (Attachment B), which defines what is meant by gender-responsive programming (i.e. that it is not just about gender-specific groups.) This part of the evaluation served an integral role in determining the strengths and weaknesses of those agencies made available to clients with co-occurring disorders. However, it is not to say that weaknesses do not exist within the system as whole. The intention is to specifically identify gaps and barriers that are preventing COD clients from being successful in their recovery. This area is only one piece of the puzzle, and the system as a whole could be strengthened and improved upon, including services provided by all key stakeholders. As noted, three different surveys (Watson, Maclaren, Shaw, & Nolan, 2003) were ed to seven treatment providers in Dunn County to determine whether staff utilized or were willing to use EBPs. These surveys were also used to help determine how providers perceived and served clients with co-occurring mental health and substance use disorders. However, only three of the seven providers completed and returned the surveys. Therefore, in order to collect 19

25 data from a greater number of providers and ensure the data was representative of the treatment provider population, the survey was introduced to attendees at the January 2012 CJCC meeting. However, only two more surveys were received but from non-direct providers. Although the use of surveys was somewhat helpful in collecting data pertaining to perceptions and attitudes in treating COD clients, the outcome was less than positive. The findings were limited and therefore, inconclusive, due to lack of commitment by most providers to complete the surveys and were not representative of the treatment provider population. Additionally, to gain a better understanding of the primary treatment providers services, policies, and procedures, the EBP consultant facilitated a focus group, with DHS and Arbor Place in attendance. Treatment services were discussed, along with several other key components. First, it was reported that access to treatment is sometimes a problem, with some clients waiting two weeks for an intake, between four to five weeks for an appointment with a psychiatrist at DHS, and between three to four weeks for an appointment with a therapist at DHS. Second, Arbor Place reported they are recruiting COD staff and started a COD group in January within their residential program; they did not report which curricula they are using ( not a set curricula ). It appears no COD group exists yet in the outpatient program. It does appear that Arbor Place has implemented some positive changes in this regard (e.g., reduced waitlist from 22 days to 10 days); perhaps some lessons learned from there could be shared with other programs. Third, the two groups reported using each other s completed assessment instruments and not making clients re-do long assessment forms at each site if clients are being treated at two different places for MH and SA. Lastly, Arbor Place reported they do have a women s group and are using a curricula, but did not provide the name of it. 20

26 Based on review of policies, procedures and interview data, and the focus group of providers, some of the EBPs from the list on page one already exist in the County to at least some degree in one or more locations. Again, fidelity reviews have not been done, and this is based only on the sources listed above. The existing EBPs are as follows: CBT (Arbor, DHS) DBT (Arbor) Diversion/Re-entry EMDR (Arbor) Family Psychoeducation (Arbor) MAT (DHS, Mayo) MI (Arbor) Psychiatric Rehabilitation (Aurora - CSP) 12-Step Facilitation (Arbor) Gender-specific/responsive programming (Arbor) Recovery-Oriented Care (Arbor) Supported Employment (Aurora) Trauma-Specific Service (Arbor) It is suspected that all agencies are doing some level of MI, CBT, Family Psychoeducation, 12- step facilitation, recovery-oriented care and trauma services, but they may not be listed in their policies and procedures or specifically noted in the interview data. On-site reviews are the best method of determining if practices are present and to what degree. Consensus on thresholds for considering a practice implemented or not is important. The practices missing from the service system include the following: ACT COS DDCAT IMR IDDT/DDCMHT Person-Centered Recovery Planning Supportive Housing Trauma-informed Care 21

27 In terms of the core components listed in the section above, specific to co-occurring disorders, onsite reviews are required to determine the extent to which these are currently present at each agency/program. There can be variation across agencies, but also across programs within agencies. Additionally, as mentioned, an employment workshop to educate employers on the benefits and importance of hiring CJP was held in February Only two agencies attended the workshop, Workforce Resource and Manpower. They were not employers per say but represented employment services and were recruited to assist with tasks, such as discussing this workshop with other employers and spreading the word about the employment project and its goals. In fact, Manpower staff members reported they would be speaking to their clients about the need and importance of hiring CJP. Both organizations reported having interest in the employment project, educating their community contacts, spreading the word about the project and its goals, and attending bimonthly CJCC meetings. Although only two of the thirty-two companies invited were in attendance, the workshop was considered a success. Agencies had the opportunity to learn from each other and suggest ideas for improvements in this area, as well as learn about the CJCC and its goals. All parties brought a wealth of information to the table. This particular workshop is something that has not been accomplished thus far in this community. Recommendations/Components This evaluation demonstrates the need to implement a more effective protocol for the treatment of co-occurring MH and SA disorders in Dunn County. Therefore, several components are recommended and are as follows: standardized screening measures, integrated services, supported employment, trauma-informed and trauma-specific services, and quality assurance/data collection tools. Additionally, problems related to continuity of care, treatment 22

28 appointment availability, medication management, funding for services, and collaboration among providers should be addressed and are important components to consider. Overall, it is recommended that problems in the system are met with evidence-based/best practices solutions. Therefore, along with the suggested components, an evidence-based and best practices database has been included, as well as the suggested treatment protocol for Dunn County. Screening and Assessment Problem. Often, individuals with co-occurring disorders in any system are not properly identified as having multiple disorders and this precludes early interventions that could help individuals enter recovery earlier than they would otherwise. Providers often develop their own screening forms, but these are not standardized and validated tools. Several standardized mental health and substance use screening measures are available in the public domain. They are brief, require little training and offer a valid mechanism for beginning the process of identifying individuals with signs of co-occurring disorders in order to facilitate comprehensive assessments and treatment. Evidence-Based Solution: Implementation of Standardized Screening Measures. Programs should be administering standardized mental health and substance use screening tools to all clients being admitted to their programs. Four popular tools that are in the public domain are listed here that programs could choose from: o Modified Mini mental health screening o Mental Health Screening Form-III o CAGE-AID o Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD) 23

29 All four of these screening measures can be downloaded from this site: Programs could pick one of these mental health screens and one of the substance use screens, for an integrated screening package at all sites. Not all programs need to use the exact same set of screening measures. In addition, the screening measures recommended for adults (Modified Mini, MHSF-III, CAGE-AID, SSI-AOD) can also be used for youth/adolescents (down to age of 12). Integrated Services Problem. Integrated services are needed because the research indicates a fragmented approach does not work. Integrated treatment means mental illness and addictive disorders services and interventions are delivered simultaneously at the same treatment site, ideally with cross-trained staff (NAMI, , background and understanding the issue section). Integrating services is not a new concept; however, for many years, many substance use and mental health treatment providers have been operating separately (NHS Confederation, 2009). This presents a problem when the evidence demonstrates a need to treat the COD at the same time, preferably by the same group at the same place. In fact, NAMI has consistently argued in recent years that the existing evidence base of scientific research already strongly supports the efficacy of integrated treatment (NAMI, , another study authorized section). Evidence-based Solution: Integrated Services. Integrated services are a necessity in Dunn County, especially if the goal is to enhance continuity of care for this particular population. Ideally, the current mental health providers would provide integrated MH and SA services for individuals with the more severe mental health problems (e.g., schizophrenia). This means they would need to ideally become licensed to deliver SA services; typically this is not a big leap for 24

30 MH agencies to do because SA services are in the scope of practice of licensed MH practitioners. On the other side, the current SA providers would provide integrated MH and SA services for individuals with the low/moderate mental health problems (e.g., depression, anxiety). This means that ideally they would get licensed as a mental health program as well, which is more of a leap because it would include adding a prescriber, if they do not already have one and this is expensive. It also means adding some clinical staff with MH education, training and/or expertise. In this way, the MH Figure 1. Quadrant Model providers would be providing integrated services to individuals in quadrants II and IV and the SA providers would provide integrated services to individuals in quadrant III. Trying to provide integrated services across agencies does not typically work well. It is recommended that treatment services be provided by the same staff at the same location. So, specific to Dunn County, diversion court clients with COD would be diverted to integrated treatment programs. IDDT and DDC/DDE can be used/applied in each agency or parts of each agency so the overall level of care is integrated for the client. Agencies do not need to be combined to implement integrated care. This does require that staff within these agencies receive training, technical assistance, coaching and supervision to increase their competencies to provide integrated care. Ideally, providers want a system that has no wrong door, meaning individuals can be screened and assessed at the agency/program they are referred to or happen to enter. These different intake portals can provide diagnoses and knowing the diagnoses and level of functioning, an individual s quadrant is also known. There are several integrated treatment 25

31 curricula available and can be found in the appendix. All DDC providers/staff can use these curricula. Also, Rhonda McKillip provides training on her curriculum, The Basics. Hazelden also provides trainers for their Co-Occurring Disorders Program (CDP), and they are listed in the appendix as well. Integrated treatment (not parallel or sequential treatment) is recommended for juveniles as well. When working with this population it is even more important to include the family in the treatment planning and treatment itself, so the EBPs for adolescents tend to be in-home treatment models. By designing a system like the one above, continuity of care would be enhanced, and individuals would not be shuffling back and forth between agencies. Database of Evidence-Based & Best Practices As mentioned earlier, accompanying this report is an excel spreadsheet (Attachment B) listing 22 evidence-based or best practices for adults with mental health and/or substance use disorders. Ideally, a system of care would have these components available in at least one location. The listing includes the name of the practice, a brief definition, including a link to one or more websites with more information about the practice, the diagnoses the practice would be used for, and the stages of change that the practice would be appropriate for. 26

32 This list can be searched using the find function or sorted in various ways. The 22 practices are listed here: Assertive Community Treatment (ACT) Cognitive Behavioral Therapy (CBT) Consumer-Operated Services Dialectical Behavior Therapy (DBT) Diversion & Re-Entry Services Dual Diagnosis Capability in Addiction Treatment (DDCAT) Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) or IDDT Eye Movement Desensitization & Reprocessing (EMDR) Family Psychoeducation Gender Responsive Services Illness Management & Recovery (IMR) Integrated Dual Disorders Treatment (IDDT) or DDCMHT Medication Assisted Treatment (MAT) Motivational Interviewing (MI) Person-Centered Recovery Planning (PCRP) Psychiatric Rehabilitation Recovery-Oriented Care Supported Employment Supportive Housing Trauma-Informed Care Trauma-Specific Services 12-Step Facilitation Some of these practices are embedded in others. For example, MI and CBT are embedded in the DDCAT, DDCMHT and IDDT models, which are the core models for individuals with cooccurring disorders. Recommended treatment also exists for juveniles. A list of EBP (Attachment C) specifically for children and adolescents can be found at the following link: Suggested treatments for various disorders are listed in the chart, but it does not appear that COD are specifically referenced. Also, some of the same EBPs recommended for adults (i.e., CBT, DBT, motivational interviewing) are listed, but other practices are identified as well (i.e., multisystemic therapy, 27

33 functional family therapy, multidimensional treatment foster care, family therapy). In some cases, some of the practices suggested in the treatment protocol for adults would not be indicated for children and adolescents (e.g., 12 step programs). Treatment Protocol The following recommended treatment protocol for individuals with co-occurring disorders is specific to Dunn County, Wisconsin, and its four main behavioral health providers. The protocol uses the list of EBP (page 26) and is displayed below. Diversion Arbor Place For individuals with moderate mental health problems and co-occurring substance use disorders (Quadrant III): CBT DBT DDCAT EMDR Family Psychoeducation Gender Responsive MAT MI PCRP Recovery-Oriented Care Trauma-Informed Care Trauma-Specific Services 12-Step Facilitation Jail MH/SA Standardized Screens; In-Jail Integrated Treatment Re-Entry Services Comprehensive Assessments Dunn County Human Services Aurora Community Services Mayo Behavioral Health Services For individuals with severe mental illnesses and co-occurring substance use disorders (Quadrants II, IV): ACT CBT Consumer-operated services DBT DDCMHT or IDDT EMDR Family Psychoeducation Gender Responsive IMR MAT MI PCRP Psychiatric Rehabilitation Recovery-Oriented Care Supported Employment Supportive Housing Trauma-Informed Care Trauma-Specific Services 12-Step Facilitation 28

34 Arbor Place is the County s main addiction treatment provider. As part of this recommended treatment protocol, they would develop the capacity over time to provide integrated mental health and addiction treatment for individuals with low-moderate mental health problems and co-occurring substance use disorders. Those integrated services would ideally include access to the list of EBPs/Best Practices listed in the Arbor Place box above. Dunn County Human Services (DHS), Aurora Community Services, and Mayo Clinic Behavioral Health Services provide mental health services; Aurora and DHS also provide some addiction treatment services. As part of this recommended treatment protocol, these providers would develop the capacity over time to provide integrated mental health and addiction treatment for individuals with severe mental health illnesses and co-occurring substance use disorders. Those integrated services would ideally include access to the list of EBPs/Best Practices listed in their box above. The jail/criminal justice system box illustrates the importance of Diversion, In-Jail Integrated Treatment, and Re-Entry Services. It would be important for either criminal justice staff or community behavioral health providers to administer standardized mental health and substance use screening measures to all individuals, as described in the previous recommendation. After identification of individuals with signs of co-occurring disorders, those individuals in jail or in community-based treatment settings need a comprehensive mental health and substance use assessment. Attachment H includes an Assessment Guidance document from Connecticut that can be used to guide the development of comprehensive assessment tools at all sites. In addition to the specific practice recommendations above for the different subpopulations of individuals with co-occurring disorders, it would be important for there to be a 29

35 mechanism for stakeholders to do a number of joint activities, if they are not already doing them: Case reviews of treatment non-responders or others at high risk; critical incident tracking and analysis; client outcome tracking; and ongoing fidelity reviews. Changes of this magnitude often require a project manager, project staff, and a steering committee to plan, initiate and monitor action steps. The Appendix to this report includes several documents created in other states that may be helpful to a change process in Dunn County: Sample Co-Occurring Policy Statement, sample Logic Model, Co-Occurring Capable and Enhanced Program Guidelines, the DDCAT, DDCMHT and IDDT Fidelity Scales, Co- Occurring Competencies for individual practitioners, a sample action plan template, and a sample brochure that could be modified for use in Dunn County. Employment Services Problem. Employment is a key component to recovery management of mental health and/or substance use disorders, yet many obstacles to employment are in the way of individuals with these disorders. In order to meet the criminogenic need of employment, communities need to provide the building blocks for criminal justice participants to stand on while living within the walls of jail or prison or while preparing for re-entry into the community. This means laying the foundation for clients to stand on by eradicating stigmatizations surrounding the hiring of offenders and creating a database of employers already interested and willing to hire and retain criminal justice participants. Evidence-based Solution: Supported Employment for Individuals with Mental Illnesses or Co-Occurring Disorders. Supported Employment for Individuals with Mental Illnesses is an evidence-based practice promoted by the federal Substance Abuse and Mental Health Services Administration (SAMHSA). As mentioned earlier, Supported Employment 30

36 helps people with mental illnesses (and co-occurring disorders) find and keep meaningful jobs in the community. Components of the model include consumer choice, integration of services, competitive jobs, benefits counseling, timely support, continuous services, and consumer preferences. The model is usually delivered by mental health agencies serving individuals with severe mental illnesses, some of whom have co-occurring substance use disorders. The model is spelled out in its fidelity scale (Attachment K) across 3 domains and 27 items. The domains are staffing organization and services. Some key items include: dedicated employment services staff that work with individuals across all phases of employment services; zero exclusion (i.e., anyone that wants to work will receive support); focus on competitive employment opportunities; ongoing vocational assessments; job development; individualized job searches; availability in vocational unit of diverse job types and employers; and follow along supports. Employment is a key component of recovery for many individuals. High fidelity to the supported employment model has been shown to be associated with positive outcomes for individuals in recovery. Other Considerations. Since the employment workshop was successful, it is recommended that, at a minimum, it be held annually, potentially increasing the chances of CJPs securing and retaining employment. It is also suggested that a contact person be assigned to plan and run the workshop, follow up with questions and interests of potential and current employers in the database, remain knowledable regarding current resources and benefits to employers, and serve as a liaison between clients and employers. By assigning an individual in this position, employers will have the ability to discuss and resolve issues concerning employees in the Diversion Court Program and general criminal justice population prior to immediately terminating them. Perhaps if employers are provided with a contact person to follow-up with regarding strengths and weaknesses of their employees, more clients will retain employment and 31

37 the employment program will thrive. By holding an annual workshop and continuing to develop the database, it is hoped that current employers will collaborate and share these newfound resources with other potential employers. If the number of employers on the database continues to grow and multiply, securing and retaining jobs may become easier for CJPs, as one barrier will be removed. It is also hoped that by posting accomplishments, education pieces, and invites to collaboration meetings on the website, it will encourage employers, community service sites, and the community as a whole to remain interested and invested in this project. In addition, providers should be helping to develop and build an offenders skill-set. Employment rates and earnings histories of people in prisons and jails are often low before incarceration as a result of limited education experiences, low skill levels, and the prevalence of physical and mental health problems (Council of State Governments Justice Center, n.d., Reentry Facts section). Connecticut s Department of Social Services will be releasing some new web-based training modules on their website for staff and clients on employment skills at Users would go to the e-learning tab near the top, create an account, and then go to the course catalog. The specific newly developed employment courses are not posted yet but will be made available to the public. Trauma-specific Interventions/Gender-based Programming Problem. 89 percent of the Dunn County female diversion court clients present with COD. More surprisingly, though, of these 8, none received integrated services for the COD, and four of the 8 were discharged from the program due to lack of progress or continued chemical use (Eberhard, , Evaluation of Diversion Court). Moreover, collectively, none of the primary treatment providers in Dunn County are offering integrated services for this population, 32

38 male or female, and there appears to be a dearth of trauma-informed care and trauma-specific interventions. Evidence-based Solution: Trauma-informed and trauma-specific services. Traumainformed care means thoroughly incorporating, in all aspects of service delivery, an understanding of the prevalence and impact of trauma and the complex paths to healing. Trauma-informed services are designed specifically to avoid retraumatizing those who seek assistance as well as the staff working in service settings. Trauma informed approaches can be utilized by any service provider or system (direct service, advocacy, judicial) and include the following: (1) an assessment of each step in any process through the lens of trauma; (2) work practices and service delivery change as a result; (3) assessment and service changes are based on the principles of safety, trustworthiness, choice, collaboration and empowerment; (4) emphasize continuity of care and collaboration across systems; (5) engage in efforts to strengthen the resilience and protective factors of individuals impacted by and vulnerable to trauma; and (6) maintain an environment of care for staff that addresses, minimizes and treats secondary traumatic stress. By contrast, trauma-specific services have a more focused primary task: to directly address trauma and its impact and to facilitate trauma recovery. An increasing number of promising and evidence-based practices address post-traumatic stress disorder (PTSD) and other consequences of trauma, especially for people who often bring other complicating vulnerabilities (e.g., substance use, severe mental health problems, homelessness, contact with the criminal justice system) to the service setting. Trauma specific services are delivered by an organization in which service providers: (1) have a thorough understanding of the neurological, biological, psychological and social effects of trauma and violence on a person; (2) routinely screen for 33

39 trauma exposure and related symptoms; (3) use culturally appropriate evidence-based assessment and treatment for traumatic stress and associated mental health symptoms; (4) make resources available to clients on trauma exposure, its impact and treatment. In terms of implementing trauma-informed care, Drs. Maxine Harris and Roger Fallot of Community Connections agency in Washington D.C. have developed a trauma-informed care protocol. Two common manualized trauma-specific interventions include Seeking Safety and Trauma Recovery and Empowerment (TREM), both of which are available online through major bookstores for a reasonable price. Other interventions are recommended as well, including Eye Movement Desensitization & Reprocessing (EMDR). Quality Assurance Problem. Dunn County treatment providers and the criminal justice system as a whole needs to track more data, understand the definition of COD, and be able to access their treatment programs on an on-going basis. Also, staff members who serve this group may lack the particular education, training, and outlook needed to treat clients with COD appropriately. Evidence-based Solution: Client-level data collection tool, Aggregate client-level data collection tool, Program-level data collection tool. Data collection tools. There are several levels of data that would be helpful to track over time: Client-level data, Aggregate client-level summaries, and Program-level information. Client-level data collection tool. The screening results described in the previous section could be collected Countywide. The state of Connecticut collects the screening summary total scores from all screening admissions. Just by collecting the summary scores, this allows the Department to calculate (using each screen s cut-off score) the percentage of screens that are 34

40 positive (i.e., showing signs of co-occurring disorders). These percentages can assist providers and the County in planning and can also be compared to diagnosis data. Aggregate client-level data collection reporting format tool. Attached is a report template that could be populated with Dunn County data from the behavioral health providers in this community. Also attached is a second document called Co-Occurring Definition; this document defines co-occurring disorders in terms of using diagnosis data. The report uses primarily mental health and substance use diagnosis data, in addition to the demographic information. A report like this indicates how many individuals in the treatment settings are diagnosed as having cooccurring disorders (COD), what quadrants they are in, the demographics of the individuals in the different quadrants, and the diagnostic combinations of individuals with COD. This information is very helpful for planning at all levels, including workforce development activities such as training on specific COD topics. Often, a report like this will show a small percentage of individuals as diagnosed with COD. This happens for several reasons. Based on the literature, you would expect to see about 20-50% of individuals in mental health settings as diagnosed also with a substance use disorder. And you would expect about 50-75% of individuals in addiction treatment settings to also be diagnosed with a mental health diagnosis. It would not be surprising if an initial report of Dunn County data reveals 8-10% of individuals in either type of setting with COD. This becomes a first task (i.e., ensuring providers are screening, diagnosing and documenting all diagnoses). Program-level data collection tool. It is important to assess and document the level of cooccurring capability of treatment programs. Two measures are recommended; these measures are included in the Appendix: o Dual Diagnosis Capability in Addiction Treatment (DDCAT) 35

41 o Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) These are being used widely across states to measure co-occurring capability. Each tool contains 35 items across 7 domains: Program structure, Program milieu, Assessment, Treatment, Continuity of care, Staffing and Training. Each item is rated on a 1-5 scale. The author has developed a scoring algorithm to indicate if services in the assessed program are Dual Diagnosis Capable (DDC) or Dual Diagnosis Enhanced (DDE). DDC means that a program is capable of serving people with both co-occurring SA and MH problems. To be considered DDC, a program needs to score 3 or higher on 80% or 28 of the 35 items. To be considered DDE a program needs to score 5 on 80% of the items. The treatment in DDC programs would not be fully integrated, but would have several components in place as measured by the DDCAT or other COD fidelity measure. The DDCAT is a tool that has also been modified for mental health programs and is known as the DDCMHT. Mental health programs choose either the IDDT (see below) or the DDCMHT to use. Places like to use the DDCAT and DDCMHT across MH and SA systems because it is the same "yardstick" or measurement tool (both 35 items, 7 domains, same scoring algorithm, etc). The federal Substance Abuse and Mental Health Services Administration (SAMHSA) recently released web-based toolkits to use along with these measures: SAMHSA also promotes the Integrated Dual Disorders Treatment (IDDT) model (mentioned above) for mental health providers to implement. This model is used for individuals with severe mental illnesses and co-occurring substance abuse/dependence disorders, in mental health agencies. The IDDT model is well suited for specialty teams providing integrated treatment. This 36

42 fidelity scale is also included in the appendix. In summary, this report introduces three COD fidelity scales: IDDT, DDCMHT, and DDCAT. A program would choose only one of these to measure its co-occurring capability. All three can be summarized to say if the program is addiction or mental health only, dual diagnosis capable, or dual diagnosis enhanced. These fidelity assessments take about a half-day onsite at a program to complete. The results provide important concrete information for the program on how to increase their cooccurring capability and can be easily used to develop an implementation plan in an overall change process to increase a program s co-occurring capability. It is recommended that fidelity reviews be completed at least annually, and it is often helpful if they are done more frequently at the beginning of a change process. With fidelity review results, the County could look at countylevel results across levels of care and by program to see where to target resources for improvement. All programs should be at least Dual Diagnosis Capable (DDC). Additional Considerations Continuity of care. Continuity of care between and within treatment episodes and with periods of incarceration or hospitalization is very important for a person s prognosis. There are several components of continuity of care to include: how COD is addressed in discharge planning, including ongoing medication management; assertive linkage to cod-welcoming 12- step groups in the individual s home community. The extent that an individual develops a longterm therapeutic alliance with the same clinician/staff, the better. Treatment appointment availability. Only 7 percent to 17 percent of prisoners who meet DSM criteria for alcohol/drug dependence or abuse receive treatment in jail or prison (The National Council of State Governments Justice Center, n.d., Reentry Facts section). In jail/prison treatment services are important, including both medication, education and 37

43 counseling. In addition to increasing quality (i.e. implementation of EBPs), there should also be some strategic planning regarding access to services. There are methodologies available to assist with implementing procedural changes in clinics to reduce no-show rates, reduce waitlists, etc. (e.g., NIATx). More clinics are moving to same-day access for intake appointments. Walk-in models or same-day access for intake appointments are used but not recommended for ongoing treatment, as person needs to develop a strong therapeutic alliance with the same clinician over time. Medication management. In many communities it is not uncommon to have a shortage of prescribers in all behavioral health treatment settings. Staff-sharing, consultant relationships and other creative arrangements can help ease this issue. Often addiction treatment programs will contract with a prescriber for a small number of hours to provide on-site medication evaluation and management for their clients. Funding for services. While funding for behavioral health services is always in short supply, funding for co-occurring disorders in particular is not necessarily more problematic as one might suspect. Individual and group sessions can include integrated treatment curricula. Such curricula are available free or at low cost. It is important that staff members are trained to screen, assess, and treat COD; there are real costs to this workforce development. The two training curricula for staff that would be recommended are as follows: FIT Focus on Integrated Treatment - $15/module from Hazelden 35 modules. University of SouthFlorida free online training 38

44 Ongoing supervision of direct care staff is critical to enhance skill development. Medication management in addiction treatment settings can be an added cost if not already implemented. While beyond the scope of this paper, some communities across the country have developed unique ways to raise additional resources for behavioral health services Collaboration and teamwork for the betterment of the community. In addition to these components, it is important to note that collaboration among all service providers, CJCC members, and other interested community members must continue to exist. As mentioned earlier, as part of the evaluation, agency s policies and procedures were requested in writing in order to review services provided. Although all of the agencies eventually responded, it is important to note that communication and timely responses were a problem for some providers. Also, only 43 percent of the surveys used to determine perceptions and attitudes of providers were returned. This outcome and other data could be an indication that communication and collaboration among those who treat the criminal justice population s mental health and substance use needs could be improved. In fact, while the evaluation was taking place, it was recommended to the CJCC that the council be able to define co-occurring disorders and develop a vision statement or policy statement surrounding this topic so that everyone is on the same page. After all, At the forefront of any successful reentry program is a strong collaborative structure between criminal justice and mental health agencies in the community (Carmody, 2008, p.4). Conclusion Clients with co-occurring substance use and mental health disorders need to know their treatment needs will be met and that they are receiving the very best services available to them. Jail walls, empty pockets, turf wars, and shifting of blame and responsibilities should be omitted and replaced with open communication, additional resources for treatment, and accountability. In 39

45 addition to revising the system that is currently operating, providers and other key stakeholders need to revise the ways in which providers collaborate. After all, clients count on the system and the people working within it to look out for their best interests. The entire operation impacts the outcome of this population s treatment and future success, whether they succeed or fail, whether they remain in or return to jail. The outcome of creating and implementing a more effective treatment protocol based on EBP/best practices for clients with COD will not only change the way a client navigates through the system or whether he or she succeeds. A system change can benefit agency staff members as well. Special expertise derived from learning an EBP can improve self-perceptions of professional accomplishment and self-efficacy to effectively work with clients, to gain employment, and to promote one s practice (Aarons, 2006, Future Directions section). It can also reduce financial and social challenges. NAMI Fresno ( ) states the following: Consequences for society directly stem from the above. Just the back-and-forth treatment alone currently given to non-violent persons with dual diagnosis is costly. Moreover, violent or criminal consumers, no matter how unfairly afflicted, are dangerous and also costly. Those with co-occurring disorders are at high risk to contract AIDS, a disease that can affect society at large. Costs rise even higher when these persons, as those with cooccurring disorders have been shown to do, recycle through healthcare and criminal justice systems again and again. Without the establishment of more integrated treatment programs, the cycle will continue (Education and Training, mental illnesses section, para. 12). An effective protocol has the potential to decrease recidivism, decrease jail and prison population, increase community safety, and free up resources for other needs. In addition, an 40

46 effective treatment protocol could potentially save the county money in the long run, due to decreased recidivism rates. For example, if one Diversion Court client is successful in the community upon his or her release and does not become reincarcerated in the local jail, that is a minimum potential savings of $45 per day (B. Reid, personal communication, 2012). Moreover, in consideration of the diversion court program, 89 percent of the female diversion court clients in Dunn County present with COD, and none of them received integrated services (Ebarhard, ). When referencing the above savings for one client, implementing integrated services for eight clients with COD could potentially save the county $360 per day, $10, 800 per month or a total of $64, 800 for six months. This is a general estimate and does not include additional costs related to other justice services and behavioral services. While implementing the new protocol will involve some spending up front, this is only one example of possible longterm financial benefits for Diversion Court and Dunn County. According to SAMHSA (2011): The new working definition of Recovery from Mental Disorders and Substance Use Disorders is as follows: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential (para. 2). If this treatment protocol is implemented, it has the potential to impact those individuals in the justice system who are in recovery or entering recovery. By choosing to make small or large changes in the system, each and every community member has the opportunity to help eliminate barriers that prevent or hinder change within this population. Big or small, the walls need to come down and the holes filled in. While it will take compassion, time, effort, teamwork, and 41

47 additional expenses in the short-term, making the necessary changes could put money back into Dunn County members pockets in the long-run and make communities feel whole again. Everyone vested in the community should ask themselves what changes they are willing to make in order to make a difference in how and whether criminal justice clients access much needed services and receive continuity of care. By designing a system like the one above, staff would be enhancing continuity of care. Everyone can reap the rewards of coming together and investing in positive changes, and everyone has some sort of a tie to this population, whether it is a brother, sister, child, co-worker, classmate, parent, or small group member in one s place of worship. Calling Dunn County one s home means caring about its well being and investing in its future. Instead of building walls, together, build a roadmap to improve services and outcomes for individuals with co-occurring disorders and for those seeking to better their lives through employment. Project findings and recommendations were presented at the March 22, 2012 CJCC meeting. Please refer to for highlights and additional information. The COD Report and Employment Project Database will be housed at this site for viewing and will potentially enhance collaboration efforts in these areas (CJP employment and COD treatment). 42

48 References Aarons, G. A. (2006). Measuring provider attitudes toward evidence-based practice: Consideration of organizational context and individual differences. (Future Directions section). Child and Adolescent Psychiatric Clinics of North America, 14 (2), doi: /j.chc Carmody, J. (2008). Reentry for safer communities: Effective county practices in jail to community transition planning for offenders with mental health and substance use disorders. (p. 4). Retrieved March 7, 2012, from Commission on Youth. (2011). Collection of evidence-based practices for children and adolescents with mental health treatment needs, 4th edition. Retrieved April 15, 2012, from Corporation for National & Community Service. (2012). Benefits of service. (For Individuals section). Retrieved April 2, 2012, from Council of State Governments Justice Center. (n.d.). The National Reentry Resource Center. (Reentry Facts section). Retrieved February 21, 2012, from Dr. Susie Eberhard, Evaluation of Diversion Court Pilot with Analysis of Programming, 8/2008- May 11, Dunn County Department of Human Services. (2012). Human Services. (the Department provides section). Retrieved March 7, 2012, from 43

49 Finn, P. (1998). Successful job placement for ex-offenders: The center for employment opportunities. (para. 1). (No ). Retrieved February 2, 2012, from Giard, J. (2008). Serving individuals with co-occurring mental health and substance use disorders: systems and practice issues. (p.12). Retrieved January 15, 2012, from Latessa, E. J. and Lowenkamp, C. (n.d.). Mind Body Awareness Project. (Curriculum:6 Criminogenic Needs/Factors section). Retrieved January 31, 2012, from NAMI. ( ). Integrated treatment and blended funding for co-occurring mental and addictive disorders. (background and understanding the issue section). Retrieved February 6, 2012, from ement/contentdisplay.cfm&contentid=28735 NAMI. ( ). Integrated treatment and blended funding for co-occurring mental and addictive disorders. (another study authorized section). Retrieved February 6, 2012, from ement/contentdisplay.cfm&contentid=28735 NAMI. (2010). The high costs of cutting mental health. Retrieved March 25, 2012, from 44

50 NAMI Fresno. ( ). Dual diagnosis and integrated treatment of mental illness and substance abuse disorder (Education and Training, mental illnesses section, para. 12). Retrieved April 27, 2012, from NHS Confederation & National Mental Health Development Unit. (2009). Seeing double: Meeting the challenge of dual diagnosis, 189, Retrieved February 1, 2012, from Peters, R. H. (2008). Importance of early diagnosis and appropriate care. [Figure 1. Quadrant Model.] (p. 8). (B. Reid, personal communication, 2012). Dunn County Sheriff s Office. Sacks, S., Chandler, R., & Gonzales, J. (2008). Responding to the challenge of co-occurring disorders: Suggestions for future research. (introduction section 1.0). Journal of Substance Abuse Treatment, 34 (1), doi: /j.jsat Retrieved February 2, 2012, from SAMHSA. (2011). SAMHSA News Release. (para.2). Retrieved February 24, 2012, from The Council of State Governments Justice Center. (n.d.). The report. (chapter 7, Policy Statement 37). Retrieved February 21, 2012, from U.S. Census Bureau. (2011). State and county quickfacts. Retrieved February 1, 2012, from Watson, Maclaren, Shaw, and Nolan (2003). Measuring staff attitudes to people with drug problems: The development of a tool. Retrieved January 10, 2012, from 45

51 Winnipeg Regional Health Authority and The Addictions Foundation of Manitoba. (2001). Models of service for persons with co-occurring mental health and substance use disorders: A review of the literature. (p. 1). Retrieved March 7, 2012, from Wisconsin Mental Health State Plan. ( ). Wisconsin s adult mental health plan. (p. 82). Retrieved April 27, 2012, from 46

52 Attachment A: Agencies Interviewed Arbor Place, Inc. Luther Midelfort Behavioral Health Aurora Community Services Marriage and Family Health Services Caillier Clinic Marshfield Clinic Behavioral Services-Menomonie Clearwater Counseling and Personal Growth Center Center Clinical Services Center-UW Stout Mayo Clinic Behavioral Health Services Dunn County District Court Judges Omne Clinic, Inc. Dunn County Human Services Behavioral Health Pierce County Staff Dunn County Interim Police Chief Rogers Memorial Hospital, Wisconsin Dunn County Jail Administration/Staff Stepping Stones First Things First The Bridge to Hope Great Rivers The Healing Place at Sacred Heart Hospital, Eau Claire, Heinz Psychological Services Wisconsin L.E. Phillips-Libertas Treatment Center The Wellness Shack LSS Mental health and Counseling Services 47

53 Attachment B: Evidence-based Practices/Best Practices EBP/Best Practice Definition Diagnoses Stage of Change Assertive Community Treatment (ACT) ACT provides assertive outreach, mental health treatment, health, vocational, integrated dual disorder treatment, family education, wellness skills, community linkages, and peer support. These services are provided to individuals by a mobile, multi-disciplinary team in community settings. Evidence-Based-Practices-EBP-KIT/SMA Severe mental illnesses, with or without co-occurring substance use disorder(s) All Cognitive Behavioral Therapy (CBT) Cognitive behavior therapy (CBT) is a type of psychotherapeutic treatment that helps individuals to understand the thoughts and feelings that influence behaviors. Cognitive behavior therapy is generally shortterm and focused on helping individuals deal with a very specific problem. During the course of treatment, individuals learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior. Wide range of disorders, including depression, anxiety, phobias, addiction Action Consumer-Operated Services A consumer-operated service is an independent organization that is owned, administratively controlled, and operated by mental health consumers. It may offer a range of services, but it emphasizes self-help and recovery. Consumer-Operated Services is an evidence-based practice (EBP) that has consistently demonstrated effectiveness in helping people with mental illness achieve their desired goals. Evidence-Based-Practices-EBP-KIT/SMA CD-DVD Severe mental illnesses, with or without co-occurring substance use disorder(s) All 48

54 Dialectical Behavioral Therapy (DBT) Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment developed by Marsha Linehan, Ph.D., and her colleagues at the University of Washington with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. "Dialectical" refers to the issues involved in treating patients with multiple disorders and to the type of thought processes and behavioral styles used in the treatment strategies. DBT has five components: (1) capability enhancement (skills training); (2) motivational enhancement (individual behavioral treatment plans); (3) generalization (access to therapist outside clinical setting, homework, and inclusion of family in treatment); (4) structuring of the environment (programmatic emphasis on reinforcement of adaptive behaviors); and (5) capability and motivational enhancement of therapists (therapist team consultation group). DBT emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapists follow a detailed procedural manual. Borderline Personality Disorder; Depression, Anxiety Action Diversion & Re-Entry Services Specially-skilled evaluation and treatment services for individuals with serious mental illness and/or substance use disorders who become involved in the criminal justice system, and to serve the courts and other components of the criminal justice system. Efforts are intended to promote recovery and prevent or limit criminal justice system involvement to the extent possible, to promote public safety and to coordinate activities with other state and private agencies. Services span the continuum of the criminal justice system from pre-booking to end of sentence after incarceration and return to the community. All All 49

55 Dual Diagnosis Capability in Addiction Treatment (DDCAT) The Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index is a program-level assessment used to inform addiction treatment agencies and others about a program s ability to provide co-occurring services. The DDCAT examines seven areas: program structure, program milieu, assessment, treatment, continuity of care, staffing and training. Programs are ranked along a continuum from Addiction Only Services, Dual Diagnosis Capable, and Dual Diagnosis Enhanced. This measure is being used in over 30 states to improve services for individuals with co-occurring mental health and substance use disorders. Co-Occurring Disorders (Quadrant III) All Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) The Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index is a program-level assessment used to inform addiction treatment agencies and others about a program s ability to provide co-occurring services. The DDCMHT examines seven areas: program structure, program milieu, assessment, treatment, continuity of care, staffing and training. Programs are ranked along a continuum from Mental Health Only Services, Dual Diagnosis Capable, and Dual Diagnosis Enhanced. This measure is being used in over 30 states to improve services for individuals with co-occurring mental health and substance use disorders. Co-Occurring Disorders (Quadrants II, IV) All 50

56 Eye Movement Desensitization & Reprocessing (EMDR) EMDR is a one-on-one form of psychotherapy that is designed to reduce trauma-related stress, anxiety, and depression symptoms associated with posttraumatic stress disorder (PTSD) and to improve overall mental health functioning.is a comprehensive, integrative psychotherapy approach. It contains elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies. EMDR psychotherapy is an information processing therapy and uses an eight phase approach to address the experiential contributors of a wide range of pathologies. It attends to the past experiences that have set the groundwork for pathology, the current situations that trigger dysfunctional emotions, beliefs and sensations, and the positive experience needed to enhance future adaptive behaviors and mental health. PTSD; traumarelated stress, anxiety, and depression symptoms associated with PTSD Action Family Psychoeducation Family Psychoeducation is a method of working in collaboration with clients and their families and other natural supports to support the consumer s recovery. Psychoeducation can be delivered to individual families or in multi-family formats. The American Psychiatric Association and the Agency for Health Care Policy and Research cite family psychoeducation as being one of the most effective ways to promote recovery. Family Psychoeducation goes beyond simply education to directly working with consumers and their families in individual or multi-family group sessions. Goals for Family Psychoeducation: Consumer, family and providers work collaboratively to support recovery; imparts information about disorders; development of coping skills; facilitate movement toward consumer goals. Based-Practices-EBP-KIT/SMA Severe mental illnesses, with or without co-occurring substance use disorder(s) All 51

57 Gender-Responsive Services Gender-responsive services includes creating an environment through site selection, staff selection, program development, content, and material that reflects an understanding of the realities of the lives of women and girls that addresses and responds to their strengths and challenges All Illness Management and Recovery (IMR) Illness Management and Recovery (IMR) is a series of weekly sessions with a specially trained mental health practitioner. Consumers learn how to develop their own personal strategies for coping with mental illness and moving forward in their life. The sessions are in an individual or group format and last between 3 to 6 months. There are specific goals of the IMR. The first goal is that consumers learn about mental illness and strategies for treatment. Second, the goal is to see a reduction in symptoms, relapses and rehospitalizations. Last, making progress towards their goals and toward recovery are important outcomes of the program. During IMR, consumers receive educational handouts, planning sheets and checklists. Consumers apply the contents of the handouts to develop their own strategies for managing mental illness and setting and achieving goals. Consumers have opportunities to practice their own personalized strategies in the sessions and in everyday life. Severe mental illnesses, with or without co-occurring substance use disorder(s) Action 52

58 Integrated Dual Disorders Treatment (IDDT) Consumers receive combined treatment for mental illnesses and substance use disorders from the same practitioner or treatment team. Components of the model include integrated services, cross-trained practitioners, stage-wise treatment, motivational interventions, cognitive behavioral treatment, multiple formats, and integrated medication services. Co-Occurring Disorders (Quadrants II, IV) All Medication Assisted Treatment (MAT) MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful. In the U.S., MAT has been demonstrated to be effective in the treatment of alcohol dependence with Food and Drug Administration approved drugs such as disulfiram, naltrexone and acamprosate; and opioid dependence with methadone, naltrexone and buprenorphine. Alcohol, Opioid Dependence Action 53

59 Motivational Interviewing (MI) Motivational interviewing is a style of consumer-centered counseling developed to facilitate change in behaviors. The core principle of the approach is negotiation rather than conflict. Motivational (MI) was developed by William R. Miller, Ph.D., and Stephen Rollnick, Ph.D. Motivational interviewing is a directive, consumer-centered counseling style that aims to help consumers explore and resolve their ambivalence about behavior change. It combines elements of style (warmth and empathy) with technique (e.g. focused reflective listening and the development of discrepancy). A core tenet of the technique is that the consumer s motivation to change is enhanced if there is a gentle process of negotiation in which the consumer, not the clinician, articulates the benefits and costs involved. A strong principle of this approach is that conflict is unhelpful and that a collaborative relationship between clinician and consumer, in which they tackle the problem together, is essential. All Precontemplation, Contemplation, Preparation Person Centered Recovery Planning (PCRP) Person Centered Recovery Planning has been recognized by the Institute of Medicine, National Administration for Health Care Quality, and other nationally recognized bodies as essential in assuring that care planning is consumer and family driven, individually responsive, addresses the needs and preferences of the whole person (especially the restoration of valued social roles), and is culturally relevant. All All 54

60 Psychiatric Rehabilitation All patients suffering from severe and persistent mental illness require rehabilitation. The goal of psychiatric rehabilitation is to help disabled individuals to develop the emotional, social and intellectual skills needed to live, learn and work in the community with the least amount of professional support. The overall philosophy of psychiatric rehabilitation comprises two intervention strategies. The first strategy is individual-centered and aims at developing the patient's skills in interacting with a stressful environment. The second strategy is ecological and directed towards developing environmental resources to reduce potential stressors. Most disabled persons need a combination of both approaches. The refinement of psychiatric rehabilitation has achieved a point where it should be made readily available for every disabled person. Severe mental illnesses, with or without co-occurring substance use disorder(s) Action Recovery-Oriented Care Recovery Oriented Systems of Care is an over-arching set of principles to guide behavioral health service delivery. Seventeen principles of ROSC are outlined at the SAMHSA link below. In 2008, DMHAS, in partnership with the Yale Program for Recovery and Community Health (PRCH) released the second edition of the Practice Guidelines for Recovery-Oriented Care for Mental Health and Substance Use Conditions. All All Supported Employment Supported Employment helps people with mental illnesses find and keep meaningful jobs in the community. Components of the model include consumer choice, integration of services, competitive jobs, benefits counseling, timely support, continuous services, and consumer preferences. Based-Practices-EBP-KIT/SMA Severe mental illnesses, with or without co-occurring substance use disorder(s) Action 55

61 Supportive Housing Supportive Housing combines affordable housing, most often through a rental subsidy, with intensive yet flexible support services. These services focus on housing based case management, or assisting the tenant to reintegrate into the community by teaching him/her the basic skills of tenancy. Supportive Housing has proven to reduce higher cost institutional services, such as homeless shelters, inpatient psychiatric and physical hospitalizations, as well as readmission into the criminal justice system. Evidence-Based-Practices-EBP-KIT/SMA Severe mental illnesses, with or without co-occurring substance use disorder(s) All Trauma-Informed Care When a human service program takes the step to become traumainformed, every part of its organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services. Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization. All All 56

62 Trauma-Specific Services Trauma-specific interventions are designed specifically to address the consequences of trauma in the individual and to facilitate healing. Treatment programs generally recognize the following: The survivor's need to be respected, informed, connected, and hopeful regarding their own recovery; the interrelation between trauma and symptoms of trauma (e.g., substance abuse, eating disorders, depression, and anxiety); and the need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers. Some wellknown trauma-specific interventions include Seeking Safety and Trauma Recovery and Empowerment (TREM). PTSD, others with history of trauma Action 12-Step Facilitation Twelve-step facilitation is an active engagement strategy designed to increase the likelihood of an individual becoming affiliated with and actively involved in 12-step self-help groups. While the efficacy of 12- step programs (and 12-step facilitation) in treating alcohol dependence has been established, the research on other areas is more preliminary but promising for helping individuals sustain recovery. The National Institute of Drug Abuse (NIDA) has recognized the need for more research in this area. Substance use disorders Preparation, Action, Relapse Prevention 57

63 Attachment C: Reference Chart of Disorders and Evidence-based Treatment (Children and Adolescents) Attachment D: COD Definition Purpose The Connecticut Department of Mental Health and Addiction Services (DMHAS) Operational Definition of Individuals with Co-Occurring Disorders for Use with DMHAS Statewide Data Systems DMHAS Co-Occurring Disorders Initiative One of the three main goals in the SAMHSA funded Co-Occurring State Incentive Grant (COSIG) awarded to Connecticut in 2005 is to promote dissemination of information and data-based decision-making related to co-occurring disorders. In order to accomplish this goal, the Initiative needed an operational definition of COD, using diagnoses, to allow analyses of available data in Connecticut s statewide data systems (i.e., DMHAS Provider Access System (DPAS) and Behavioral Healthcare Information System (BHIS)). The creation of a formal operational definition of COD allows COD-related analyses, as envisioned in Connecticut s COSIG application, at statewide, provider agency, and program levels. The use of these data provides information to DMHAS and providers on processes of care being used with people with COD, and outcomes for people with COD. These indicators can be tracked over time to inform program development efforts and provide information useful in evaluating and modifying current programs. Objective A co-occurring disorder (COD) is defined as at least one mental health disorder together with at least one substance use disorder. An objective of the Department of Mental Health and Addiction Services (DMHAS) Co-Occurring Disorders Initiative is to have an operational definition of co-occurring disorders for use with its statewide data systems. The operational definition of COD in this document should in no way restrict clinical staff from using the full array of diagnoses that are available in the DSM-IV-TR to adequately identify and characterize the nature of an individual s behavioral health concerns. The listings in this document were compiled to have a simple mechanism to arrange the DSM-IV disorders, and consequently define the combinations of disorders that reflect the Co-Occurring Disorders population for use with DMHAS statewide data systems. 58

64 Numerical diagnostic codes from International Classification of Diseases, 9th Edition, Clinical Modification, (ICD-9) have been used in this Operational Definition. According to the Centers for Medicare and Medicaid Services all DSM-IV-TR diagnosis codes are compatible with ICD-9 Codes 1. Since in some instances ICD-9 codes include a 5th digit where the DSM-IV does not, ICD-9 codes were chosen to ensure that all possible diagnostic codes are included in this definition 2. In collaboration with providers, DMHAS anticipates using this COD operational definition for the following analyses using data in the DPAS and BHIS: The percentage of people that screen positive for signs of co-occurring disorders relative to the percentage of people identified as having co-occurring disorders; The percentage of people served by DMHAS operated and funded providers that have co-occurring disorders; The percentage of people with COD in each of the four quadrants of the four quadrant model (see figure 1 below); Outcomes for people with co-occurring disorders relative to outcomes for people who do not have co-occurring disorders; and Outcomes for people with co-occurring disorders served in integrated programs relative to outcomes for people with co-occurring disorders served in non-integrated programs. Figure 1. Four Quadrant Model. Alcohol and other Drug Abuse III (LH) Less severe mental health disorder/ High severe substance use disorder Locus of care: Substance abuse system I (LL) IV (HH) More severe mental health disorder/ High severe substance use disorder Locus of care: Mental health system, State hospitals, jails/prisons, emergency rooms, etc. II (HL) 1 The American Psychiatric Association, (DSM-IV-TR coding issues). Retrieved October 18, 2007, from DSM-IV-TR Diagnostic and Statistical Manual Web site: 2 The American Psychiatric Association, (Summary of Coding Discrepancies). DSM-IV-TR coding issues. Retrieved October 18, 2007, from DSM-IV-TR Diagnostic and Statistical Manual Web site: 59

65 Low Severit y Less severe mental health disorder/ Less severe substance use disorder Locus of care: Primary health care settings High severe mental health disorder/ Less severe substance use disorder Locus of care: Mental health system Mental Illness Source: NASMHPD and NASADAD, High Severity Operational Definition of Individuals with Co-Occurring Disorders The proposed definition includes persons who meet the diagnostic criteria for one or more Axis I mental health disorders or Axis II personality disorders AND one or more substance-related disorders per ICD-9 codes and the DSM IV-TR. Please see Appendix A and Appendix B for the list of mental health and substance use diagnoses included (and not included) in this definition. An active client is defined as a person who is receiving services during the fiscal year being examined. All diagnoses associated with these active admissions are included in the analysis, including diagnoses given before the FY being examined. There are individuals in DPAS and BHIS that either have no diagnoses (codes missing), or diagnosis is deferred (799.9), or they were identified as having no diagnosis or condition (V71.09). Individuals with no diagnoses in the time period being examined are not included in COD related analyses. 60

66 Lists of Mental Health and Substance Use Diagnoses This list contains mental health diagnoses included in the Connecticut operational definition of co-occurring disorders (COD). The codes with an in the In columns are included in this definition of COD. The codes with an in the Out columns are not included in this definition of COD. If the diagnosis is checked in the high column within the In column, it is included in the Connecticut definition of severe mental illness (SMI) for purposes of the four quadrant analyses. Different sources have different definitions of SMI (e.g., DMHAS, SAMHSA, NASMHPD). A picture of the four quadrant model is on page 2 of this document and includes these categories: Quadrant I: Low mental health disorders and low substance use disorders Quadrant II: High mental health disorders (i.e., severe mental illnesses) and low substance use disorders Quadrant III: High substance use disorders and low mental health disorders (i.e., non-smi) Quadrant IV: High mental health disorders and high substance use disorders NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH IN LOW OUT 290 DEMENTIA Senile dementia uncomplicated Presenile dementia Presenile dementia uncomplicated Presenile dementia with delirium Presenile dementia with acute confusional state Presenile dementia with delusional features Presenile dementia, paranoid type Presenile dementia with depressive features Presenile dementia, depressed type Senile dementia with delusional or depressive features Senile dementia with delusional features Senile dementia with depressive features Senile dementia with delirium Senile dementia with acute confusional state Vascular dementia Vascular dementia Multi-infarct dementia or psychosis Vascular dementia uncomplicated Vascular dementia uncomplicated 61

67 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH IN LOW Vascular dementia with delirium Vascular dementia with delirium Arteriosclerotic dementia with acute confusional state Vascular dementia with delusions Vascular dementia with delusions Arteriosclerotic dementia, paranoid type Vascular dementia with depressed mood Vascular dementia with depressed mood Arteriosclerotic dementia, depressed type Other specified senile psychotic conditions Presbyophrenic psychosis Unspecified senile psychotic condition *part of 292 series in substance use Amphetamine-Related disorder NOS, Cocaine related disorder NOS, Hallucinogen-related disorder NOS, Inhalant-related disorder NOS, Nicotine-related disorder NOS. Opioid-related disorder NOS, Phencyclidine related disorder NOS, Sedative, hypnotic, or anxiolytic disorder NOS, Other (or unknown) substance related disorder NOS Unspecified drug-induced mental disorder Drug-related disorder NOS Organic psychosis NOS due to or associated with drugs 293 TRANSIENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE Delirium due to a general medical condition Delirium due to conditions classified elsewhere Subacute delirium Other specified transient mental disorders due to conditions classified elsewhere Psychotic disorder due to a general medical condition with delusions Psychotic disorder with delusions in conditions classified elsewhere, Transient organic psychotic condition, paranoid type OUT 62

68 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Psychotic disorder due to a general medical condition with hallucinations Psychotic disorder with hallucinations in conditions classified elsewhere, Transient organic psychotic condition, hallucinatory type Mood disorder due to a general medical condition Mood disorder in conditions classified elsewhere, Transient organic psychotic condition, depressive type Anxiety disorder due to a general medical condition Anxiety disorder in conditions classified elsewhere Catatonic disorder due to a general medical condition Other: Catatonic disorder in conditions classified elsewhere Mental disorder NOS due to a general medical condition Unspecified transient mental disorder in conditions classified elsewhere 294 PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE Amnestic disorder due to a general medical condition Amnestic disorder in conditions classified elsewhere, Korsakoff's psychosis or syndrome (nonalcoholic) Dementia of the Alzheimer s Type Dementia due to other general medical conditions Dementia in conditions classified elsewhere Dementia of the Alzheimer s Type without behavioral disturbance Dementia due to other general medical conditions without behavioral disturbance Dementia in conditions classified elsewhere Dementia of the Alzheimer's type Code first any underlying physical condition Dementia of the Alzheimer s Type with behavioral disturbance Dementia in conditions classified elsewhere with behavioral disturbance, Aggressive behavior, Combative behavior, Violent behavior, Wandering off HIGH IN LOW OUT 63

69 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Dementia NOS Amnestic disorder NOS Other persistent mental disorders due to conditions classified elsewhere, Amnestic disorder NOS, Dementia NOS, Epileptic psychosis NOS, Mixed paranoid and affective organic psychotic states Cognitive Disorder NOS Unspecified persistent mental disorders due to conditions classified elsewhere, Cognitive disorder NOS, Organic psychosis (chronic) HIGH IN LOW OUT 295 SCHIZOPHRENIC DISORDERS Simple type Schizophrenia Simple type Schizophrenia unspecific Simple type Schizophrenia subchronic Simple type Schizophrenia chronic Simple type Schizophrenia subchronic with acute exacerbation Simple type Schizophrenia chronic with acute exacerbation Simple type Schizophrenia in remission Disorganized type, Hebephrenia, Hebephrenic type schizophrenia Schizophrenia disorganized type Unspecific Disorganized type, Hebephrenia, Hebephrenic type schizophrenia subchronic Disorganized type, Hebephrenia, Hebephrenic type schizophrenia chronic Disorganized type, Hebephrenia, Hebephrenic type schizophrenia subchronic with acute exacerbation Disorganized type, Hebephrenia, Hebephrenic type schizophrenia chronic with acute exacerbation Disorganized type, Hebephrenia, Hebephrenic type schizophrenia in remission 64

70 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH Catatonic type, Catatonic (schizophrenia) Schizophrenia catatonic type Unspecific Catatonic type, Catatonic (schizophrenia) subchronic Catatonic type, Catatonic (schizophrenia) chronic Catatonic type, Catatonic (schizophrenia)subchronic with acute exacerbation Catatonic type, Catatonic (schizophrenia) chronic with acute exacerbation Catatonic type, Catatonic (schizophrenia) in remission Paranoid type, Paraphrenic schizophrenia Schizophrenia paranoid type Paranoid type, Paraphrenic schizophrenia unspecific Paranoid type, Paraphrenic schizophrenia subchronic Paranoid type, Paraphrenic schizophrenia chronic Paranoid type, Paraphrenic schizophrenia subchronic with acute exacerbation Paranoid type, Paraphrenic schizophrenia chronic with acute exacerbation Paranoid type, Paraphrenic schizophrenia in remission Schizophreniform disorder,oneirophrenia, Schizophreniform: attack psychosis, confusional type Schizophreniform disorder Schizophreniform disorder,oneirophrenia, Schizophreniform: attack psychosis, confusional type unspecific Schizophreniform disorder,oneirophrenia, Schizophreniform: attack psychosis, confusional type subchronic Schizophreniform disorder,oneirophrenia, Schizophreniform: attack psychosis, confusional type chronic Schizophreniform disorder,oneirophrenia, Schizophreniform: attack psychosis, confusional type subchronic with acute exacerbation IN LOW OUT 65

71 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Schizophreniform disorder,oneirophrenia, Schizophreniform: attack psychosis, confusional type chronic with acute exacerbation Schizophreniform disorder,oneirophrenia, Schizophreniform: attack psychosis, confusional type in HIGH remission Latent schizophrenia Latent schizophrenia Unspecific Latent schizophrenia Subchronic Latent schizophrenia Chronic Latent schizophrenia Subchronic with acute exacerbation Latent schizophrenia Chronic with acute exacerbation Latent schizophrenia in remission Schizophrenic disorders residual type Schizophrenia residual type Schizophrenic disorders residual type unspecific Schizophrenic disorders residual type subchronic Schizophrenic disorders residual type chronic Schizophrenic disorders residual type subchronic with acute exacerbation Schizophrenic disorders residual type chronic with acute exacerbation Schizophrenic disorders residual type in remission Schizoaffective disorder Schizoaffective disorder Schizoaffective disorder unspecific Schizoaffective disorder subchronic Schizoaffective disorder chronic Schizoaffective disorder subchronic with acute exacerbation Schizoaffective disorder chronic with acute exacerbation Schizoaffective disorder in remission Other specified types of schizophrenia Other specified types of schizophrenia unspecific IN LOW OUT 66

72 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH Other specified types of schizophrenia subchronic Other specified types of schizophrenia chronic Other specified types of schizophrenia subchronic with acute exacerbation Other specified types of schizophrenia chronic with acute exacerbation Other specified types of schizophrenia in remission Unspecified schizophrenia Schizophrenia undifferentiated type Unspecified schizophrenia unspecific Unspecified schizophrenia subchronic Unspecified schizophrenia chronic Unspecified schizophrenia subchronic with acute exacerbation Unspecified schizophrenia chronic with acute exacerbation Unspecified schizophrenia in remission IN LOW OUT 296 EPISODIC MOOD DISORDERS Bipolar I disorder single manic episode Bipolar I disorder, single manic episode Bipolar I disorder, single manic episode unspecified Bipolar I disorder, single manic episode unspecified Bipolar I disorder, single manic episode mild Bipolar I disorder, single manic episode mild Bipolar I disorder, single manic episode moderate Bipolar I disorder, single manic episode moderate Bipolar I disorder, single manic episode severe without mention of psychotic behavior Bipolar I disorder, single manic episode severe without mention of psychotic behavior Bipolar I disorder, single manic episode severe specified as with psychotic behaviors Bipolar I disorder, single manic episode severe specified as with psychotic behaviors 67

73 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH Bipolar I disorder, single manic episode in partial or unspecified remission Bipolar I disorder, single manic episode in partial or unspecified remission Bipolar I disorder, single manic episode in full remission Bipolar I disorder, single manic episode in full remission Manic disorder, recurrent episode Manic disorder, recurrent episode unspecified Manic disorder, recurrent episode mild Manic disorder, recurrent episode moderate Manic disorder, recurrent episode severe without mention of psychotic behavior Manic disorder, recurrent episode severe specified as with psychotic behaviors Manic disorder, recurrent episode in partial or unspecified remission Manic disorder, recurrent episode in full remission Major depressive disorder single episode Major depressive disorder, single episode Major depressive disorder, single episode unspecified Major depressive disorder, single episode unspecified Major depressive disorder, single episode mild Major depressive disorder, single episode mild Major depressive disorder, single episode moderate Major depressive disorder, single episode moderate Major depressive disorder, single episode severe without psychotic features Major depressive disorder, single episode severe without mention of psychotic behavior Major depressive disorder, single episode severe with psychotic features Major depressive disorder, single episode severe specified as with psychotic behaviors IN LOW OUT 68

74 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Major depressive disorder, single episode in partial remission Major depressive disorder, single episode in partial or unspecified remission Major depressive disorder, single episode in full remission Major depressive disorder, single episode in full remission Major depressive disorder recurrent Major depressive disorder, recurrent episode Major depressive disorder, recurrent unspecified Major depressive disorder, recurrent episode unspecified Major depressive disorder, recurrent mild Major depressive disorder, recurrent episode mild Major depressive disorder, recurrent moderate Major depressive disorder, recurrent episode moderate Major depressive disorder, recurrent severe without psychotic features Major depressive disorder, recurrent episode severe without mention of psychotic behavior Major depressive disorder, recurrent with psychotic features Major depressive disorder, recurrent episode severe specified as with psychotic behaviors Major depressive disorder, recurrent in partial remission Major depressive disorder, recurrent episode in partial or unspecified remission Major depressive disorder, recurrent in full remission Major depressive disorder, recurrent episode in full remission Bipolar I disorder, most recent episode hypomanic Bipolar I disorder, most recent episode (or current) manic Bipolar I disorder, most recent episode manic unspecified Bipolar I disorder, most recent episode (or current) manic unspecified Bipolar I disorder, most recent episode manic mild Bipolar I disorder, most recent episode (or current) manic mild IN HIGH LOW OUT 69

75 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Bipolar I disorder, most recent episode manic moderate Bipolar I disorder, most recent episode (or current) manic moderate Bipolar I disorder, most recent episode manic severe without psychotic features Bipolar I disorder, most recent episode (or current) manic severe without mention of psychotic behavior Bipolar I disorder, most recent episode manic severe with psychotic features Bipolar I disorder, most recent episode (or current) manic severe specified as with psychotic behaviors Bipolar I disorder, most recent episode manic in partial remission Bipolar I disorder, most recent episode (or current) manic in partial or unspecified remission Bipolar I disorder, most recent episode manic in full remission Bipolar I disorder, most recent episode (or current) manic in full remission Bipolar I disorder, most recent episode depressed Bipolar I disorder, most recent episode (or current) depressed Bipolar I disorder, most recent episode depressed unspecified Bipolar I disorder, most recent episode (or current) depressed unspecified Bipolar I disorder, most recent episode depressed mild Bipolar I disorder, most recent episode (or current) depressed mild Bipolar I disorder, most recent episode depressed moderate Bipolar I disorder, most recent episode (or current) depressed moderate Bipolar I disorder, most recent episode depressed severe without psychotic features Bipolar I disorder, most recent episode (or current) depressed severe without mention of psychotic behavior IN HIGH LOW OUT 70

76 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Bipolar I disorder, most recent episode depressed severe with psychotic features Bipolar I disorder, most recent episode (or current) depressed severe specified as with psychotic behaviors Bipolar I disorder, most recent episode depressed in partial remission Bipolar I disorder, most recent episode (or current) depressed in partial or unspecified remission Bipolar I disorder, most recent episode depressed in full remission Bipolar I disorder, most recent episode (or current) depressed in full remission Bipolar I disorder, most recent episode mixed Bipolar I disorder, most recent episode (or current) mixed Bipolar I disorder, most recent episode mixed unspecified Bipolar I disorder, most recent episode (or current) mixed unspecified Bipolar I disorder, most recent episode mixed mild Bipolar I disorder, most recent episode (or current) mixed mild Bipolar I disorder, most recent episode mixed moderate Bipolar I disorder, most recent episode (or current) mixed moderate Bipolar I disorder, most recent episode mixed severe without psychotic features Bipolar I disorder, most recent episode (or current) mixed severe without mention of psychotic behavior Bipolar I disorder, most recent episode mixed severe with psychotic features Bipolar I disorder, most recent episode (or current) mixed severe specified as with psychotic behaviors Bipolar I disorder, most recent episode mixed in partial remission Bipolar I disorder, most recent episode (or current) mixed in partial or unspecified remission IN HIGH LOW OUT 71

77 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Bipolar I disorder, most recent episode mixed in full remission Bipolar I disorder, most recent episode (or current) mixed in full remission Bipolar I disorder, most recent episode unspecified Bipolar I disorder, most recent episode (or current) unspecified HIGH Bipolar disorder, unspecified Bipolar disorder NOS Other and unspecified bipolar disorders Atypical manic disorder Atypical depressive disorder Bipolar II disorder (recurrent major depressive episodes with hypomanic episodes) Other, Bipolar II disorder, Manic-depressive psychosis, mixed type Other and unspecified episodic mood disorder Mood disorder NOS Unspecified episodic mood disorder Other specified episodic mood disorder IN LOW OUT 297 DELUSIONAL DISORDERS Paranoid state, simple Delusional disorder Delusional disorder Paraphrenia Shared psychotic disorder (Folie a Deux) Shared psychotic disorder Other specified paranoid states Unspecified paranoid state 298 OTHER NON ORGANIC PSYCHOSES Other nonorganic psychoses Depressive type psychosis Other nonorganic psychoses Excitative type psychosis Other nonorganic psychoses Reactive confusion 72

78 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Other nonorganic psychoses Acute paranoid reaction Other nonorganic psychoses Psychogenic paranoid psychosis Brief psychotic disorder Other nonorganic psychoses Other and unspecified reactive psychosis Psychotic disorder NOS Other nonorganic psychoses Unspecified psychosis HIGH IN LOW OUT 300 ANIETY STATES Anxiety disorder NOS Anxiety state, unspecified Panic disorder without agoraphobia Panic disorder without agoraphobia Generalized anxiety disorder Generalized anxiety disorder Other Dissociative, conversion and factitious disorders Hysteria, unspecified Conversion disorder Conversion disorder Dissociative amnesia (formerly psychogenic amnesia) Dissociative amnesia Hysterical amnesia Dissociative fugue (formerly psychogenic fugue) Dissociative fugue Hysterical fugue Dissociative identity disorder (formerly multiple personality disorder) Dissociative identity disorder Dissociative disorder NOS Dissociative disorder or reaction, unspecified Factitious disorder with predominantly psychological signs and symptoms Factitious disorder with predominantly psychological signs and symptoms 73

79 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH IN LOW Factitious disorder with predominantly physical signs and symptoms Factitious disorder with combined psychological and physical signs and symptoms Factitious disorder NOS Other and unspecified factitious illness Phobic disorders Phobia unspecified Panic disorder with agoraphobia Agoraphobia with panic disorder Agoraphobia without history of panic disorder Agoraphobia without mention of panic attacks Social phobia (Social anxiety disorder) Social phobia Specific phobia (formerly Simple phobia) Other isolated or specific phobias Obsessive-compulsive disorder Obsessive-compulsive disorders, Anancastic neurosis, Compulsive neurosis, Obsessional phobia [any] Dysthymic disorder Dysthymic disorder Cyclothymic disorder Neurasthenia Depersonalization disorder Depersonalization disorder Hypochondriasis Body dysmorphic disorder Hypochondriasis Somatoform disorders Somatization disorder Somatization disorder Undifferentiated somatoform disorder Somatoform disorder NOS Undifferentiated somatoform disorder Other somatoform disorders OUT 74

80 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Unspecified mental disorder (non psychotic) Unspecified nonpsychotic mental disorder, Psychoneurosis NOS HIGH IN LOW OUT 301 PERSONALITY DISORDERS Paranoid personality disorder Paranoid personality disorder Affective personality disorder Affective personality disorder, unspecified Chronic hypomanic personality disorder Chronic depressive personality disorder Schizoid personality disorder Schizoid personality disorder Schizoid personality disorder, unspecified Introverted personality Schizotypal personality disorder Schizotypal personality disorder Explosive personality disorder Obsessive-compulsive personality disorder Obsessive-compulsive personality disorder Histrionic personality disorder Histrionic personality disorder Histrionic personality disorder, unspecified, Hysterical personality NOS Chronic factitious illness with physical symptoms Other histrionic personality disorder Dependent personality disorder Dependent personality disorder Antisocial personality disorder Antisocial personality disorder Other personality disorders Narcissistic personality disorder Narcissistic personality disorder Avoidant personality disorder Avoidant personality disorder 75

81 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH LOW Borderline personality disorder Borderline personality disorder Passive-aggressive personality Oher Personality, eccentric, "haltlose" type, immature, masochistic, psychoneurotic Personality disorder NOS Unpecified personality disorder, pathological personality NOS, personality disorder NOS IN OUT 302 SEUAL AND GENDER IDENTITY DISORDERS Ego-dystonic sexual orientation Zoophilia Pedophilia Pedophilia Transvestic fetishism Transvestic fetishism Exhibitionism Exhibitionism Trans-sexualism Trans-sexualism With unspecified sexual history Trans-sexualism With asexual history Trans-sexualism With homosexual history With heterosexual history Gender identity disorder NOS Gender identity disorder in children Gender identity disorder in children Psychosexual dysfunction Sexual dysfunction NOS Psychosexual dysfunction, unspecified Hypoactive sexual desire disorder Psychosexual dysfunction Hypoactive sexual desire disorder 76

82 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH IN LOW Female sexual arousal disorder Male erectile disorder Psychosexual dysfunction With inhibited sexual excitement Female orgasmic disorder Female orgasmic disorder Male orgasmic disorder Male orgasmic disorder Premature ejaculation Premature ejaculation Dyspareunia not due to a general medical condition Dyspareunia, psychogenic Sexual aversion disorder With other specified psychosexual dysfunctions Other specified psychosexual disorders Fetishism Fetishism Voyeurism Voyeurism Sexual masochism Sexual masochism Sexual sadism Sexual sadism Gender identity disorder in adults Gender identity disorder in adolescents or adults Frotteurism Other, Frotteurism, Nymphomania, Satyriasis Paraphilia NOS Sexual disorder NOS Unspecified psychosexual disorder OUT 306 PHYSIOLOGICAL MALFUNCTION ARISING FROM MENTAL FACTORS Musculoskeletal Psychogenic paralysis, Psychogenic torticollis 77

83 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH LOW Physiological malfunction arising from mental factors Respiratory Psychogenic: Physiological malfunction arising from mental factors Cardiovascular Physiological malfunction arising from mental factors Skin Physiological malfunction arising from mental factors Gastrointestinal Physiological malfunction arising from mental factors Genitourinary Psychogenic genitourinary malfunction, unspecified Vaginismus not due to a general medical condition Psychogenic vaginismus Psychogenic dysmenorrhea Psychogenic dysuria Physiological malfunction arising from mental factors Physiological malfunction arising from mental factors Endocrine Physiological malfunction arising from mental factors Organs of special sense Other specified psychophysiological malfunction Unspecified psychophysiological malfunction 307 SPECIAL SYMPTOMS NOT OTHERWISE CLASSIFIED Stuttering Stuttering Anorexia nervosa Anorexia nervosa Tics Tic disorder NOS Tic disorder, unspecified Transient tic disorder Transient tic disorder Chronic motor or vocal tic disorder Chronic motor or vocal tic disorder IN OUT 78

84 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH LOW Tourette's disorder Tourette's disorder Stereotypic movement disorder Stereotypic movement disorder Specific disorders of sleep of nonorganic origin Nonorganic sleep disorder, unspecified Transient disorder of initiating or maintaining sleep Primary insomnia Persistent disorder of initiating or maintaining sleep Transient disorder of initiating or maintaining wakefulness Primary Hypersomnia Persistent disorder of initiating or maintaining wakefulness Circadian rhythm sleep disorder of nonorganic origin Sleep terror disorder Sleepwalking disorder Sleep arousal disorder, Night terror disorder Dyssomnia NOS Nightmare disorder Other dysfunctions of sleep stages or arousal from sleep Repetitive intrusions of sleep Other, "Short-sleeper", Subjective insomnia complaint Other and unspecified disorders of eating Eating disorder NOS Eating disorder, unspecified Bulimia nervosa Bulimia nervosa Pain disorders related to psychological factors Pain disorder with associated psychological factors Psychogenic pain, site unspecified Tension headache Pain disorder associated with both psychological factors and a general medical condition Pain disorders related to psychological factors, Other IN OUT 79

85 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Communication disorder NOS Other and unspecified special symptoms or syndromes, not elsewhere classified, Communication disorder NOS, Hair plucking, Lalling, Lisping, Masturbation, Nail-biting, Thumb-sucking HIGH IN LOW OUT 308 ACUTE REACTION TO STRESS Acute reaction to stress Predominant disturbance of emotions Acute reaction to stress Predominant disturbance of consciousness Acute reaction to stress Predominant psychomotor disturbance Acute stress disorder Other acute reactions to stress Mixed disorders as reaction to stress Unspecified acute reaction to stress 309 ADJUSTMENT REACTION Adjustment disorder with depressed mood Adjustment disorder with depressed mood Prolonged depressive reaction With predominant disturbance of other emotions Separation anxiety disorder Separation anxiety disorder Emancipation disorder of adolescence and early adult life Specific academic or work inhibition Adjustment disorder with anxiety Adjustment disorder with anxiety Adjustment with mixed anxiety and depressed mood Adjustment disorder with mixed anxiety and depressed mood Adjustment reaction other Adjustment disorder with disturbance of conduct Adjustment disorder with disturbance of conduct 80

86 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH IN LOW Adjustment disorder with mixed disturbance of emotions and conduct Adjustment disorder with mixed disturbance of emotions and conduct Other specified adjustment reactions Posttraumatic stress disorder Posttraumatic stress disorder Adjustment reaction with physical symptoms Adjustment reaction with withdrawal Other specified adjustment reactions Other Adjustment disorder unspecified Unspecified adjustment reaction 310 SPECIFIC NON PSYCHOTIC MENTAL DISORDERS DUE TO BRAIN DAMAGE Frontal lobe syndrome Personality change due to a general medical condition Specific nonpsychotic mental disorders due to brain damage Personality change due to conditions classified elsewhere Specific nonpsychotic mental disorders due to brain damage Postconcussion syndrome Specific nonpsychotic mental disorders due to brain damage Other specified nonpsychotic mental disorders following organic brain damage Specific nonpsychotic mental disorders due to brain damage Unspecified nonpsychotic mental disorder following organic brain damage OUT 311 DEPRESSIVE DISORDER NOS 311 Depressive disorder not otherwise specified Depressive disorder, not elsewhere classified Depressive disorder NOS 81

87 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH IN LOW OUT 312 DISTURBANCE OF CONDUCT, NOT ELSEWHERE CLASSIFIED Undersocialized conduct disorder, aggressive type Undersocialized conduct disorder, unaggressive type Socialized conduct disorder Disorders of impulse control, not elsewhere classified Impulse-control disorder NOS Impulse control disorder, unspecified Pathological gambling Pathological gambling Kleptomania Kleptomania Pyromania Pyromania Intermittent explosive disorder Intermittent explosive disorder Isolated explosive disorder Trichotillomania Impulse control disorder Other, Trichotillomania Mixed disturbance of conduct and emotions Other specified disturbances of conduct, not elsewhere classified Conduct disorder childhood onset type Conduct disorder, childhood onset type Conduct disorder adolescent onset type Conduct disorder, adolescent onset type Conduct disorder unspecified onset Other conduct disorder Disruptive behavior disorder NOS Unspecified disturbance of conduct 314 HYPERKINETIC SYNDROME OF CHILDHOOD Attention deficit/hyperactivity disorder Attention deficit disorder 82

88 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH IN LOW Attention deficit/hyperactivity disorder predominantly inattentive type Attention deficit disorder Without mention of hyperactivity, Predominantly inattentive type Attention deficit/hyperactivity disorder combined type Attention deficit/hyperactivity disorder predominantly hyperactive impulsive type Attention deficit disorder with hyperactivity, Predominantly inattentive type Hyperkinesis with developmental delay Hyperkinetic conduct disorder Other specified manifestations of hyperkinetic syndrome Attention deficit/hyperactivity disorder NOS Unspecified hyperkinetic syndrome ADDITIONAL CODES COMMONLY USED IN DSM IV 316 Psychological factors affecting medical condition Psychological factors in physical conditions classified elsewhere Sleep disorder due to (an Axis I or Axis II disorder) insomnia type Insomnia related to (an Axis I or Axis II disorder) Sleep disorder due to (an Axis I or Axis II disorder) hypersomnia type Hypersomnia related to (an Axis I or Axis II disorder) Circadian rhythm sleep disorder unspecified type Circadian rhythm sleep disorder delayed sleep phase type Circadian rhythm sleep disorder jet lag type Circadian rhythm sleep disorder shift work type Sleep disorder due to (an Axis I or Axis II disorder) parasomnia type Sleep disorder due to (an Axis I or Axis II disorder) mixed type Male erectile disorder due to a general medical condition OUT 83

89 NUMBERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH LOW Male hypoactive sexual desire disorder due to a general medical condition Male dyspareunia due to a general medical condition Other male sexual dysfunction due to a general medical condition Female dyspareunia due to a general medical condition Female hypoactive sexual desire due to a general medical condition Other female sexual dysfunction due to a general medical condition Delirium NOS IN OUT 84

90 Substance Use Disorders This list contains the substance use diagnoses that are included in the Connecticut operational definition of co-occurring disorders (COD). The codes with an in the In columns are included in this definition of COD. The diagnosis codes with an in the Out column are not included in the definition of COD. If the diagnosis is checked in the high column within the In column, it is included in the Connecticut operational definition of high substance use disorders for purposes of the proposed four quadrant analyses. A picture of the four quadrant model is on page 2 of this document and includes these categories: Quadrant I: Low mental health disorders and low substance use disorders Quadrant II: High mental health disorders (i.e., severe mental illnesses) and low substance use disorders Quadrant III: High substance use disorders and low mental health disorders (i.e., non-smi) Quadrant IV: High mental health disorders and high substance use disorders NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH IN LOW OUT 291 ALCOHOL-INDUCED MENTAL DISORDERS Alcohol Withdrawal Delirium; Alcohol Intoxication Delirium Alcohol withdrawal delirium Alcoholic delirium Delirium tremens Alcohol-induced persisting amnestic disorder Alcohol-induced persisting amnestic disorder Alcoholic polyneuritic psychosis Korsakoff's psychosis, alcoholic Wernicke-Korsakoff syndrome (alcoholic) Alcohol-induced persisting dementia Alcohol-induced persisting dementia Alcoholic dementia NOS Alcoholism associated with dementia NOS Chronic alcoholic brain syndrome Alcohol-induced psychotic disorder with hallucinations Alcohol-induced psychotic disorder with hallucinations Alcoholic: hallucinosis (acute) psychosis with hallucinosis Idiosyncratic alcohol intoxication Pathologic: alcohol intoxication drunkenness Idiosyncratic alcohol intoxication Pathologic: alcohol intoxication drunkenness 85

91 NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Alcohol-induced psychotic disorder with delusions Alcohol-induced psychotic disorder with delusions Alcoholic: paranoia psychosis, paranoid type Other specified alcohol-induced mental disorders Other specified alcohol-induced mental disorders Alcohol withdrawal Alcohol withdrawal Alcohol: abstinence syndrome or symptoms withdrawal syndrome or symptoms Alcohol induced sleep disorder Alcohol induced sleep disorders Alcohol-induced anxiety disorder, Alcohol-induced mood disorder, Alcohol-induced sexual dysfunction Other Alcohol-induced anxiety disorder Alcohol-induced mood disorder Alcohol-induced sexual dysfunction Alcohol related disorder, NOS Unspecified alcohol-induced mental disorders Alcoholic: mania NOS psychosis NOS Alcoholism (chronic) with psychosis Alcohol-related disorder NOS IN HIGH LOW OUT 292 DRUG WITHDRAWAL Amphetamine withdrawal, Cocaine withdrawal, Nicotine withdrawal, Opioid withdrawal, Sedative, hypnotic, or anxiolytic withdrawal,other (or unknown) substance withdrawal Nicotine withdrawal Drug Withdrawal Drug-induced psychotic disorders 86

92 NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Amphetamine Induced Psychotic Disorder with Delusions, Cannabis-Induced Psychotic Disorder with Delusions, Cocaine-induced psychotic disorder with delusions, Hallucinogen-induced psychotic disorder with delusions, Inhalant induced psychotic disorder with delusions, Opioid induced psychotic disorder with delusions, Phencyclidine induced psychotic disorder with delusions, Sedative, hypnotic, or anxiolytic induced psychotic disorder with delusions Other (or unknown) induced psychotic disorder with delusions Drug-induced psychotic disorder with delusions Paranoid state induced by drugs Amphetamine-induced psychotic disorder with hallucinations, Cannabis-Induced Psychotic Disorder with Hallucinations, Cocaine-induced psychotic disorder with hallucinations, Hallucinogen-induced psychotic disorder with hallucinations, Inhalant induced psychotic disorder with hallucinations, Opioid induced psychotic disorder with hallucinations, Phencyclidine induced psychotic disorder with hallucinations, Sedative, hypnotic, or anxiolytic induced psychotic disorder with hallucinations Other (or unknown) induced psychotic disorder with hallucinations Drug-induced psychotic disorder with hallucinations Hallucinatory state induced by drugs Pathological drug intoxication Pathological drug intoxication Other specified drug-induced mental disorders Amphetamine Intoxication delirium, Cannabis Intoxication Delirium, Cocaine intoxication delirium, Hallucinogen intoxication delirium, Inhalant intoxication delirium, Opioid intoxication delirium, Phencyclidine intoxication delirium, Sedative, hypnotic, or anxiolytic intoxication delirium, Sedative, hypnotic, or anxiolytic withdrawal delirium, Other (or unknown) substance induced delirium Drug-induced delirium HIGH IN LOW OUT 87

93 NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Inhalant induced persisting dementia, Sedative, hypnotic, or anxiolytic induced persisting dementia, Other (or unknown) substance induced persisting dementia Drug-induced persisting dementia Sedative, hypnotic, or anxiolytic induced persisting amnestic disorder Drug-induced persisting amnestic disorder Amphetamine Induced Mood Disorder, Cocaine induced mood disorder, Hallucinogen-induced mood disorder, Inhalant induced mood disorder, Opioid induced mood disorder, Phencyclidine induced mood disorder, Sedative, hypnotic, or anxiolytic induced mood disorder, Other (or unknown) substance induced mood disorder Drug-induced mood disorder Depressive state induced by drugs Amphetamine Induced Sleep Disorder, Cocaine induced sleep disorder, Opioid induced sleep disorder, Sedative, hypnotic, or anxiolytic induced sleep disorder, Other (or unknown) induced sleep disorder, caffeine induced sleep disorder Drug induced sleep disorders IN HIGH LOW OUT 88

94 NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Amphetamine Intoxication, Amphetamine Induced Anxiety Disorder, Amphetamine Induced Sexual Dysfunction, Cannabis Intoxication, Cannabis-induced anxiety disorder, Cannabis Related Disorder NOS, Cocaine intoxication, Cocaine-induced anxiety disorder, Cocaine-induced sexual dysfunction, Hallucinogen intoxication, Hallucinogen persisting perception disorder (flashbacks), Hallucinogen induced anxiety disorder Inhalant intoxication, Inhalant induced anxiety disorder, Opioid Intoxication, Opioid induced sexual dysfunction, Phencyclidine intoxication, Phencyclidine induced anxiety disorder, Sedative, hypnotic, or anxiolytic intoxication, Sedative, hypnotic, or anxiolytic induced anxiety disorder, Sedative, hypnotic, or anxiolytic induced sexual dysfunction, Other (or unknown) substance intoxication, Other (or unknown) substance induced anxiety disorder, Other (or unknown) substance induced sexual dysfunction, caffeine induced anxiety disorder Other, Drug-induced anxiety disorder Drug-induced organic personality syndrome Drug-induced sexual dysfunction Drug intoxication Amphetamine related disorder NOS Caffeine related disorder NOS Cannabis related disorder NOS Cocaine related disorder NOS Phencyclidine related disorder NOS Sedative, hypnotic or anxiolytic related disorder NOS Other or unknown substance related disorder NOS Hallucinogen related disorder NOS Inhalant related disorder NOS Nicotine related disorder NOS Opioid related disorder NOS 303 ALCOHOL DEPENDENCE SYNDROME Acute alcoholic intoxication, Acute drunkenness in alcoholism IN HIGH LOW OUT 89

95 NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS Alcohol intoxication Acute alcoholic intoxication, Acute drunkenness in alcoholism unspecified Acute alcoholic intoxication, Acute drunkenness in alcoholism continuous Acute alcoholic intoxication, Acute drunkenness in alcoholism episodic Acute alcoholic intoxication, Acute drunkenness in alcoholism in remission Other and unspecified alcohol dependence, Chronic alcoholism, Dipsomania Alcohol dependence Other and unspecified alcohol dependence, Chronic alcoholism, Dipsomania unspecified Other and unspecified alcohol dependence, Chronic alcoholism, Dipsomania continuous Other and unspecified alcohol dependence, Chronic alcoholism, Dipsomania episodic Other and unspecified alcohol dependence, Chronic alcoholism, Dipsomania in remission IN HIGH LOW OUT 304 DRUG DEPENDENCE Opioid type dependence Opioid dependence Opioid type dependence unpecified Opioid type dependence continuous Opioid type dependence episodic Opioid type dependence in remission Sedative, hypnotic or anxiolytic dependence Sedative, hypnotic or anxiolytic dependence Sedative, hypnotic or anxiolytic dependence unspecified Sedative, hypnotic or anxiolytic dependence continuous Sedative, hypnotic or anxiolytic dependence episodic Sedative, hypnotic or anxiolytic dependence in remission Cocaine dependence 90

96 NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH Cocaine dependence Cocaine dependence unspecified Cocaine dependence continuous Cocaine dependence episodic Cocaine dependence in remission Cannabis dependence Cannabis dependence Cannabis dependence unspecified Cannabis dependence continuous Cannabis dependence episodic Cannabis dependence in remission Amphetamine and other psychostimulant dependence Amphetamine dependence Amphetamine and other psychostimulant dependence unspecified Amphetamine and other psychostimulant dependence continuous Amphetamine and other psychostimulant dependence episodic Amphetamine and other psychostimulant dependence in remission Hallucinogen dependence Hallucinogen dependence Hallucinogen dependence unspecified Hallucinogen dependence continuous Hallucinogen dependence episodic Hallucinogen dependence in remission Other specified drug dependence Inhalant dependence Phencyclidine dependence Other specified drug dependence Other specified drug dependence unspecified Other specified drug dependence continuous Other specified drug dependence episodic IN LOW OUT 91

97 NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH Other specified drug dependence in remission Combinations of opioid type drug with any other Combinations of opioid type drug with any other unspecified Combinations of opioid type drug with any other continuous Combinations of opioid type drug with any other episodic Combinations of opioid type drug with any other in remission Combinations of drug dependence excluding opioid type drug Polysubstance dependence Combinations of drug dependence excluding opioid type drug unspecified Combinations of drug dependence excluding opioid type drug continuous Combinations of drug dependence excluding opioid type drug episodic Combinations of drug dependence excluding opioid type drug in remission Unspecified drug dependence Other (or unknown) substance dependence Unspecified drug dependence unspecified Unspecified drug dependence continuous Unspecified drug dependence episodic Unspecified drug dependence in remission IN LOW OUT 305 NONDEPENDENT USE OF DRUGS Alcohol abuse Alcohol abuse Alcohol abuse Unspecified Alcohol abuse continuous Alcohol abuse episodic Alcohol abuse in remission Tobacco use disorder 92

98 NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH LOW Nicotine dependence Tobacco use disorder unspecified Tobacco use disorder continuous Tobacco use disorder episodic Tobacco use disorder in remission Cannabis abuse Cannabis abuse Cannabis abuse unspecified Cannabis abuse continuous Cannabis abuse episodic Cannabis abuse in remission Hallucinogen abuse Hallucinogen abuse Hallucinogen abuse unspecified Hallucinogen abuse continuous Hallucinogen abuse episodic Hallucinogen abuse in remission Sedative, hypnotic or anxiolytic abuse Sedative, hypnotic or anxiolytic abuse Sedative, hypnotic or anxiolytic abuse unspecified Sedative, hypnotic or anxiolytic abuse continuous Sedative, hypnotic or anxiolytic abuse episodic Sedative, hypnotic or anxiolytic abuse in remission Opioid abuse Opioid abuse Opioid abuse unspecified Opioid abuse continuous Opioid abuse episodic Opioid abuse in remission Cocaine abuse Cocaine abuse Cocaine abuse unspecified Cocaine abuse continuous Cocaine abuse episodic IN OUT 93

99 NUMERICAL CODE DSM IV DIAGNOSIS ICD-9 DIAGNOSIS HIGH Cocaine abuse in remission Amphetamine or related acting sympathomimetic abuse Amphetamine abuse Amphetamine or related acting sympathomimetic abuse unspecified Amphetamine or related acting sympathomimetic abuse continuous Amphetamine or related acting sympathomimetic abuse episodic Amphetamine or related acting sympathomimetic abuse in remission Antidepressant type abuse Antidepressant type abuse unspecified Antidepressant type abuse continuous Antidepressant type abuse episodic Antidepressant type abuse in remission Other, mixed, or unspecified drug abuse x Other or unknown substance abuse Caffeine intoxication Phencyclidine abuse Inhalant abuse Other, mixed, or unspecified drug abuse unspecified Other, mixed, or unspecified drug abuse continuous Other, mixed, or unspecified drug abuse episodic Other, mixed, or unspecified drug abuse in remission IN LOW OUT 94

100 * Report template that could be populated with Dunn County data from the behavioral health providers in the community. Alcohol/Schizophrenia Alcohol/Bipolar Alcohol/Depressive Alcohol/PTSD Alcohol/Other Anxiety Alcohol/Eating Dis. Alcohol/Impulse Control Alcohol/Personality Dis. Alcohol/Other Alcohol/Multiple MH Year Denominator Numerator Percent Cocaine/Schizophenia Cocaine/Bipolar Cocaine/Depressive Cocaine/PTSD Cocaine/Other Anxiety Cocaine/Eating Dis. Cocaine/Impulse Control Cocaine/Personality Dis. Cocaine/Other Cocaine/Multiple MH Opioid/Schizophrenia Opioid/Bipolar Opioid/Depressive Opioid/PTSD Opioid/Other Anxiety Opioid/Eating Dis. Opioid/Impulse Control Opioid/Personality Dis. Opioid/Other 95

101 Opioid/Multiple MH Cannabis/Schizophrenia Cannabis/Bipolar Cannabis/Depressive Cannabis/PTSD Cannabis/Other Anxiety Cannabis/Eating Dis. Cannabis/Impulse Control Cannabis/Personality Cannabis/Other Cannabis/Multiple MH Amphetamine/Schizoprenia Amphetamine/Bipolar Amphetamine/Depressive Amphetamine/PTSD Amphetamine/Other Anxiety Amphetamine/Eating Dis. Amphetamine/Impulse Control Amphetamine/Personality Amphetamine/Other Amphetamine/Multiple MH Sedative, Hypnotic or Anxiolytic Use Disorders (SHA) SHA/Schizophrenia SHA/Bipolar SHA/Depressive SHA/PTSD SHA/Other Anxiety SHA/Eating Dis SHA/Impulse Control SHA/Personality SHA/Other SHA/Multiple MH 96

102 Nicotine/Schizophrenia Nicotine/Bipolar Nicotine/Depressive Nicotine/PTSD Nicotine/Other Anxiety Nicotine/Eating Dis Nicotine/Impulse Control Nicotine/Personality Nicotine/Other Nicotine/Multiple MH Polysubstance/Schizophrenia Polysubstance/Bipolar Polysubstance/Depressive Polysubstance/PTSD Polysubstance/Other Anxiety Polysubstance/Eating Dis Polysubstance/Impulse Control Polysubstance/Personality Polysubstance/Other Polysubstance/Multiple MH Other SA/Schizophrenia Other SA/Bipolar Other SA/Depressive Other SA/PTSD Other SA/Other Anxiety Other SA/Eating Dis Other SA/Impulse Control Other SA/Personality Other SA/Other Other SA/Multiple MH Year 97

103 Alcohol/Schizophrenia Alcohol/Bipolar Alcohol/Depressive Alcohol/PTSD Alcohol/Other Anxiety Alcohol/Eating Dis. Alcohol/Impulse Control Alcohol/Personality Dis. Alcohol/Other Alcohol/Multiple MH Denominator Numerator Percent Cocaine/Schizophenia Cocaine/Bipolar Cocaine/Depressive Cocaine/PTSD Cocaine/Other Anxiety Cocaine/Eating Dis. Cocaine/Impulse Control Cocaine/Personality Dis. Cocaine/Other Cocaine/Multiple MH Opioid/Schizophrenia Opioid/Bipolar Opioid/Depressive Opioid/PTSD Opioid/Other Anxiety Opioid/Eating Dis. Opioid/Impulse Control Opioid/Personality Dis. Opioid/Other Opioid/Multiple MH Cannabis/Schizophrenia 98

104 Cannabis/Bipolar Cannabis/Depressive Cannabis/PTSD Cannabis/Other Anxiety Cannabis/Eating Dis. Cannabis/Impulse Control Cannabis/Personality Cannabis/Other Cannabis/Multiple MH Amphetamine/Schizoprenia Amphetamine/Bipolar Amphetamine/Depressive Amphetamine/PTSD Amphetamine/Other Anxiety Amphetamine/Eating Dis. Amphetamine/Impulse Control Amphetamine/Personality Amphetamine/Other Amphetamine/Multiple MH Sedative, Hypnotic or Anxiolytic Use Disorders (SHA) SHA/Schizophrenia SHA/Bipolar SHA/Depressive SHA/PTSD SHA/Other Anxiety SHA/Eating Dis SHA/Impulse Control SHA/Personality SHA/Other SHA/Multiple MH Nicotine/Schizophrenia Nicotine/Bipolar 99

105 Nicotine/Depressive Nicotine/PTSD Nicotine/Other Anxiety Nicotine/Eating Dis Nicotine/Impulse Control Nicotine/Personality Nicotine/Other Nicotine/Multiple MH Polysubstance/Schizophrenia Polysubstance/Bipolar Polysubstance/Depressive Polysubstance/PTSD Polysubstance/Other Anxiety Polysubstance/Eating Dis Polysubstance/Impulse Control Polysubstance/Personality Polysubstance/Other Polysubstance/Multiple MH Other SA/Schizophrenia Other SA/Bipolar Other SA/Depressive Other SA/PTSD Other SA/Other Anxiety Other SA/Eating Dis Other SA/Impulse Control Other SA/Personality Other SA/Other Other SA/Multiple MH Attachment E: DUAL DIAGNOSIS CAPABILITY IN ADDICTION TREATMENT (DDCAT) VERSION

106 Program Identification RATING SCALE COVER SHEET Date: Rater(s): Time Spent (Hours): Agency Name: Program Name: Address: Zip Code: Contact Person: 1) ; 2) Telephone: ; FA: ; State: Region: Program ID: Time Period: (1= Baseline; 2 = 1 st -follow-up; 3= 2 nd follow-up; 4= 4 th follow-up; etc) Program Characteristics Payments received (program): Primary focus of agency: Agency type: Exclusive program/admission criteria requirement: Self-pay Addiction treatment services Private Adolescents Private health insurance Mental health services Public Co-occurring MH & SUDs disorders Medicaid Mix of addiction & MH services Non-Profit HIV/AIDs Medicare General health services For-Profit Gay & Lesbian State financed insurance Hospital Government operated Seniors/Elders Military insurance Veterans Health Admin. Pregnant/post-partum Other funding sources: Other public funds Women Residential setting for patients & their children Other funds Size of Program: Level of care: Men # of admissions/last fiscal year ASAM-PPC-2R (Addiction): DUI/DWI Capacity (highest # servable) I. Outpatient Criminal justice clients Average length of stay (in days) Planned length of stay (in days) # of unduplicated clients/year II. IOP/Partial Hospital Adult General III. Residential/Inpatient IV. Medically Managed Intensive Inpatient (Hospital) OMT: Opioid Maintenance D: Detoxification Mental Health: Outpatient Partial hospital/day program Inpatient 101

107 DUAL DIAGNOSIS CAPABILITY IN ADDICTION TREATMENT PROGRAMS (DDCAT) VERSION 4.0 RATING SCALE I. PROGRAM STRUCTURE 1 AOS 2 3 DDC 4 5 DDE IA. Primary focus of agency as stated in the mission statement (If program has mission, consider program mission). Addiction only. Primary focus is addiction, co-occurring disorders are treated. Primary focus on persons with cooccurring disorders. IB. Organizational certification and licensure. Permits only addiction treatment. Has no actual barrier, but staff report there to be certification or licensure barriers. Has no barrier to providing mental health treatment or treating cooccurring disorders within the context of addiction treatment. Is certified and/or licensed to provide both. IC. Coordination and collaboration with mental health services. D. Financial incentives. No document of formal coordination or collaboration. Meets the SAMHSA definition of minimal Coordination. Can only bill for addiction treatments or bill for persons with substance use disorders. Vague, undocumented, or informal relationship with mental health agency, or consulting with a staff member from that agency. Meets the SAMHSA definition of Consultation. Could bill for either service type if substance use disorder is primary, but staff report there to be barriers. OR- Partial Formalized and documented coordination or collaboration with mental health agency. Meets the SAMHSA definition of Collaboration. Can bill for either service type, however a substance use disorder must be primary. Formalized coordination and collaboration, and the availability of case management staff, or staff exchange programs (variably used). Meets the SAMHSA definition of Collaboration and has some informal components consistent with Integration. Most services are integrated within the existing program, or routine use of case management staff or staff exchange programs. Meets the SAMHSA definition of Integration. Can bill for addiction or mental health treatments, or their combination and/or integration. 102

108 1 AOS 2 3 DDC reimbursement for mental health services available. 4 5 DDE II. PROGRAM MILIEU IIA. Routine expectation of and welcome to treatment for both disorders. 1 AOS Program expects substance use disorders only, refers or deflects persons with mental health disorders or symptoms. 2 3 DDC Documented to expect substance use disorders only (e.g. admission criteria, target population), but has informal procedure to allow some persons with mental health disorders to be admitted. Focus is on substance use disorders, but accepts mental health disorders by routine and if mild and relatively stable as reflected in program documentation. 4 5 DDE Program formally defined like DDC but clinicians and program informally expect and treat co-occurring disorders regardless of severity, not well documented. Clinicians and program expect and treat cooccurring disorders regardless of severity, well documented. IIB. Display and distribution of literature and patient educational materials. III. CLINICAL PROCESS: ASSESSMENT IIIA. Routine screening methods for mental health symptoms. Addiction or peer support (e.g., AA) only. Pre-admission screening based on patient selfreport. Decision based on clinician inference from patient presentation or by history. Available for both disorders but not routinely offered or formally available. Pre-admission screening for symptom and treatment history, current medications, suicide/homicide history prior to admission. Routinely available for both mental health and substance use disorders in waiting areas, patient orientation materials and family visits, but distribution is less for mental health disorders. Routine set of standard interview questions for mental health using a generic framework, e.g. ASAM-PPC (Dimension III) or Biopsychosocial data collection. Routinely available for both mental health and substance use disorders with equivalent distribution. Screen for mental health symptoms using standardized or formal instruments with established psychometric properties. Routinely and equivalently available for both disorders and for the interaction between mental health and substance use disorders. Screen using standardized or formal instruments for both mental health and substance use disorders with established psychometric properties. IIIB. Routine Assessment for mental Assessment for mental Assessment for mental Assessment for mental Assessment for mental 103

109 assessment if screened positive for mental health symptoms. health disorders is not recorded in records. health disorders occurs for some patients, but is not routine or is variable by clinician. health disorders is present, formal, standardized, and documented in 50-69% of the records. health disorders is present, formal, standardized, and documented in 70-89% of the records. health disorders is formal, standardized, and integrated with assessment for substance use symptoms, and documented in at least 90% of the records. IIIC. Mental health and substance use diagnoses made and documented. 1 AOS Mental health diagnoses are neither made nor recorded in records. 2 3 DDC Mental health diagnostic The program has a impressions or past mechanism for providing treatment records are diagnostic services in a present in records but timely manner. Mental the program does not health diagnoses are have a routine process documented in 50-69% for making and of the records. documenting mental health diagnoses. 4 5 DDE The program has a Comprehensive mechanism for providing diagnostic services are routine, timely diagnostic provided in a timely services. Mental health manner. Mental health diagnoses are diagnoses are documented in 70-89% documented in at least of the records. 90% of the records. IIID. Mental health and substance use history reflected in medical record. IIIE. Program acceptance based on mental health symptom acuity: low, moderate, high. IIIF. Program acceptance based on severity and persistence of mental health disability: low, Collection of substance use disorder history only. Admits persons with no to low acuity. Admits persons in program with no to low severity and persistence of mental health disability. Standard form collects substance use disorder history only. Mental health history collected inconsistently. Routine documentation of both mental health and substance use disorder history in record in narrative section. Admits persons in program with low to moderate acuity, but who are primarily stable. Admits persons in program with low to moderate severity and persistence of mental health disability. Specific section in record dedicated to history and chronology of both disorders. Specific section in record devoted to history and chronology of both disorders and the interaction between them is examined temporally. Admits persons in program with moderate to high acuity, including those unstable in their mental health disorder. Admits persons in program with moderate to high severity and persistence of mental health disability. 104

110 moderate, high. IIIG. Stage-wise assessment. IV. CLINICAL PROCESS: TREATMENT IVA. Treatment plans. Not assessed or documented. Address addiction only (mental health not listed). Assessed and documented variably by individual clinician. Variable by individual clinician, i.e., plans vaguely or only sometimes address cooccurring mental health disorders. Clinician assessed and routinely documented, focused on substance use motivation. Plans routinely address both disorders although substance use disorders addressed as primary, mental health as secondary with generic interventions. Formal measure used and routinely documented but focusing on substance use motivation only. Plans routinely address substance use and mental health disorders; equivalent focus on both disorders; some individualized detail is variably observed. Formal measure used and routinely documented, focus on both substance use and mental health motivation. Plans routinely address both disorders equivalently and in specific detail; interventions in addition to medication are used to address mental health disorders. IVB. Assess and monitor interactive courses of both disorders. 1 AOS No documentation of progress with mental health disorders. 2 3 DDC Variable reports of Routine clinical focus in progress on mental narrative (treatment plan health disorder by review or progress note) individual clinicians. on mental health disorder change; description tends to be generic. 4 5 DDE Treatment monitoring Treatment monitoring and documentation and documentation reflecting equivalent indepth routinely reflects clear, focus on both detailed, and systematic disorders is available but focus on change in both variably used. substance use and mental health disorders. IVC. Procedures for mental health emergencies and crisis management. No guidelines conveyed in any manner. Verbally conveyed inhouse guidelines. Documented guidelines: Referral or collaborations (to local mental health agency or emergency department). Variable use of documented guidelines, formal risk assessment tools and advance directives for mental health crisis and substance use relapse. Routine capability, or a process to ascertain risk with ongoing use of substances and/or severity of mental health symptoms; maintain in program unless commitment is warranted. IVD. Stage-wise treatment. Not assessed or explicit in treatment plan. Stage of change or motivation documented Stage of change or motivation routinely Stage of change or motivation routinely Stage of change or motivation routinely 105

111 variably by individual clinician in treatment plan. incorporated into individualized plan, but no specific stage-wise treatments. incorporated into individualized plan; general awareness of adjusting treatments by substance use stage or motivation only. incorporated into individualized plan; formally prescribed and delivered stage-wise treatments for both substance use and mental health disorders. IVE. Policies and procedures for medication evaluation, management, monitoring and compliance. Patients on medication routinely not accepted. No capacities to monitor, guide prescribing or provide psychotropic medications during treatment. Certain types of medication are not acceptable, or patient must have own supply for entire treatment episode. Some capacity to monitor psychotropic medications. Present, coordinated medication policies. Some access to prescriber for psychotropic medications and policies to guide prescribing are provided. Monitoring of the medication is largely provided by the prescriber. Clear standards and routine for medication prescriber who is also a staff member. Routine access to prescriber and guidelines for prescribing in place. The prescriber may periodically consult with other staff regarding medication plan and recruit other staff to assist with medication monitoring. Clear standards and routine for medication prescriber who is also a staff member. Full access to prescriber and guidelines for prescribing in place. The prescriber is on the treatment team and the entire team can assist with monitoring. IVF. Specialized interventions with mental health content. 1 AOS Not addressed in program content. 2 3 DDC Based on judgment by In program format as individual clinician; generalized intervention variable penetration into (e.g. stress management) routine services. with penetration into routine services. Routine clinician adaptation of an evidence-based addiction treatment (e.g. MI, CBT, Twelve-Step Facilitation). 4 5 DDE Some specialized Routine mental health interventions by symptom management specifically trained groups; individual clinicians in addition to therapies focused on routine generalized specific disorders; interventions. systematic adaptation of an evidence-based addiction treatment (e.g. MI, CBT, Twelve-Step Facilitation). IVG. Education about mental health disorders, treatment, Not offered. Generic content, offered variably or by clinician judgment. Generic content, routinely delivered in individual and/or group Specific content for specific co-morbidities; variably offered in Specific content for specific co-morbidities; routinely offered in 106

112 and interaction with substance use disorders. formats. individual and/or group formats. individual and/or group formats. IVH. Family education and support. For substance use disorders only, or no family education at all. Variably or by clinician judgment. Mental health disorders routinely but informally incorporated into family education or support sessions. Available as needed. Generic family group on site on substance use and mental health disorders, variably offered. Structured group with more routine accessibility. Routine and systematic co-occurring disorder family group integrated into standard program format. Accessed by families of the majority of patients with cooccurring disorders. IVI. Specialized interventions to facilitate use of peer support groups in planning or during treatment. No interventions used to facilitate use of either addiction or mental health peer support. Used variably or infrequently by individual clinicians for individual patients, mostly for facilitation to addiction peer support groups. Generic format on site, but no specific or intentional facilitation based on mental health disorders. More routine facilitation to addiction peer support groups (e.g. AA, NA). Variable facilitation targeting specific cooccurring needs, intended to engage patients in addiction peer support groups or groups specific to both disorders (e.g. DRA, DTR). Routine facilitation targeting specific cooccurring needs, intended to engage patients in addiction peer support groups or groups specific to both disorders (e.g. DRA, DTR). IVJ. Availability of peer recovery supports for patients with cooccurring disorders. Not present, or if present not recommended. Off site, recommended variably. Off site and facilitated with contact persons or informal matching with peer supports in the community, some cooccurring focus. Off site, integrated into plan, and routinely documented with cooccurring focus. On site, facilitated and integrated into program (e.g. alumni groups); routinely used and documented with cooccurring focus. V. CONTINUITY OF CARE VA. Co-occurring disorders addressed in discharge planning process. 1 AOS Not addressed. 2 3 DDC Variably addressed by individual clinicians. Co-occurring disorders systematically addressed as secondary in planning process for off site referral. 4 5 DDE Some capacity (less than 80% of the time) to plan for integrated follow-up, i.e., equivalently address both substance use and mental health disorders Both disorders seen as primary, with confirmed plans for on-site followup, or documented arrangements for off-site follow-up; at least 80% 107

113 as a priority. of the time. VB. Capacity to maintain treatment continuity. No mechanism for managing ongoing care of mental health needs when addiction treatment program is completed. No formal protocol to manage mental health needs once program is completed, but some individual clinicians may provide extended care until appropriate linkage takes place. Variable documentation. No formal protocol to manage mental health needs once program is completed, but when indicated, most individual clinicians provide extended care until appropriate linkage takes place. Routine documentation. Formal protocol to manage mental health needs indefinitely, but variable documentation that this is routinely practiced, typically within the same program or agency. Formal protocol to manage mental health needs indefinitely and consistent documentation that this is routinely practiced, typically within the same program or agency. VC. Focus on ongoing recovery issues for both disorders. Not observed. Individual clinician determined. Routine focus is on recovery from addiction, mental health symptoms are viewed as potential relapse issues only. Routine focus on addiction recovery and mental health management and recovery, both seen as primary and ongoing. VD. Specialized interventions to facilitate use of community-based peer support groups during discharge planning. No interventions made to facilitate use of either addiction or mental health peer support groups upon discharge. Used variably or infrequently by individual clinicians for individual patients, mostly for facilitation to addiction peer support groups upon discharge. Generic, but no specific or intentional facilitation based on mental health disorders. More routine facilitation to addiction peer support groups (e.g. AA, NA) upon discharge. Assertive linkages and interventions variably made targeting specific co-occurring needs to facilitate use of addiction peer support groups or groups specific to both disorders (e.g. DRA, DTR) upon discharge. Assertive linkages and interventions routinely made targeting specific co-occurring needs to facilitate use of addiction peer support groups or groups specific to both disorders (e.g. DRA, DTR) upon discharge. VE. Sufficient supply and compliance plan 1 AOS No medications in plan. 2 3 DDC Variable or Routine 30-day or supply undocumented to next appointment off- 4 5 DDE Maintains medication Maintains medication management in management in program 108

114 for medications is documented. availability of 30-day or supply to next appointment off-site. site. Prescription and confirmed appointment documented. program/agency until admission to next level of care at different provider (e.g., days). Prescription and confirmed admission documented. with provider. VI. STAFFING VIA. Psychiatrist or other physician or prescriber of psychotropic medications. No formal relationship with a prescriber for this program. Consultant or contractor off site. Consultant or contractor on site. Staff member, present on site for clinical matters only. Staff member, present on site for clinical, supervision, treatment team, and/or administration. VIB. On site clinical staff members with mental health licensure (doctoral or masters level), or competency or substantive experience. Program has no staff who are licensed as mental health professionals or have had substantial experience sufficient to establish competence in mental health treatment. 1-24% of clinical staff have either a license in a mental health profession or substantial experience sufficient to establish competence in mental health treatment % of clinical staff have either a license in a mental health profession or substantial experience sufficient to establish competence in mental health treatment % of clinical staff have either a license in a mental health profession or substantial experience sufficient to establish competence in mental health treatment. 50% or more of clinical staff have either a license in a mental health profession or substantial experience sufficient to establish competence in mental health treatment. VIC. Access to mental health clinical supervision or consultation. No access. Consultant or contractor off site, variably provided. Provided as needed or variably on site by consultant, contractor or staff member. Routinely provided on site by staff member. Routinely provided on site by staff member and focuses on in-depth learning. VID. Case review, staffing or utilization review procedures emphasize and support co-occurring disorder treatment. Not conducted. Variable, by off site consultant, undocumented. Documented, on site, and as needed coverage of co-occurring issues. Documented, routine, but not systematic coverage of co-occurring issues. Documented, routine and systematic coverage of co-occurring issues. 109

115 VIE. Peer/Alumni supports are available with co-occurring disorders. 1 AOS Not available. 2 3 DDC Available, with cooccurring disorders, but occurring disorders, but Available, with co- as part of the as part of the community. Variably community. Routine referred by individual referrals made thru clinicians. clinician relationships or more formal connections such as peer support service groups (e.g. AA Hospital and Institutional committees or NAMI). 4 5 DDE Available on site, with Available on site, with co-occurring disorders, co-occurring disorders, either as paid staff, either as paid staff, volunteers, or program volunteers, or program alumni. Variable referrals alumni. Routine referrals made. made. VII. TRAINING VIIA. All staff members have basic training in attitudes, prevalence, common signs and symptoms, detection and triage for co-occurring disorders. No staff have basic training (0% trained). Variably trained, no systematic agency training plan or individual staff member election (1-24% of staff trained). Certain staff trained, encouraged by management and with systematic training plan (25-50% of staff trained). Many staff trained and monitored by agency strategic training plan (51-79% of staff trained). Most staff trained and periodically monitored by agency strategic training plan (80% or more of staff trained). VIIB. Clinical staff members have advanced specialized training in integrated psychosocial or pharmacological treatment of persons with co-occurring disorders. No clinical staff have advanced training (0% trained). Variably trained, no systematic agency training plan or individual staff member election (1-24% of clinical staff trained). Certain staff trained, encouraged by management and with systematic training plan (25-50% of clinical staff trained). Many staff trained and monitored by agency strategic training plan (51-79% of clinical staff trained). Most staff trained and periodically monitored by agency strategic training plan (80% or more of clinical staff trained). Site Visit Notes: 110

116 I. Program Structure DUAL DIAGNOSIS CAPABILITY IN ADDICTION TREATMENT (DDCAT) VERSION 4.0 SCORING SUMMARY IV. Clinical Process: Treatment V. Continuity of Care 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 A. B. C. D. E. F. G. H. I. J. Sum Total = /10 = SCORE DDCAT INDE PROGRAM CATEGORY: SCALE METHOD OVERALL SCORE (Sum of Scale Scores/7): DUAL DIAGNOSIS CAPABILITY: AOS (1-1.99) AOS/DDC (2-2.99) DDC (3-3.49) DDC/DDE ( ) DDE ( ) 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 DDCAT INDE PROGRAM CATEGORY: CRITERION METHOD % CRITERIA MET FOR AOS (# of 1 or > /35): _100% % 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): 111

117 Attachment F: DUAL DIAGNOSIS CAPABILITY IN MENTAL HEALTH TREATMENT (DDCMHT) VERSION 4.0 Program Identification RATING SCALE COVER SHEET Date: Rater(s): Time Spent (Hours): Agency Name: Program Name: Address: Contact Person: 1) ; 2) Telephone: ; FA: ; State: Region: Program ID: Time Period: (1= Baseline; 2 = 1 st -follow-up; 3= 2 nd follow-up; 4= 4 th follow-up; etc) Program Characteristics Payments received (program): Primary focus of agency: Agency type: Exclusive program/admission criteria requirement: Self-pay Addiction treatment services Private Adolescents Private health insurance Mental health services Public Co-occurring MH & SUDs disorders Medicaid Mix of addiction & MH services Non-Profit HIV/AIDs Medicare General health services For-Profit Gay & Lesbian State financed insurance Hospital Government operated Seniors/Elders Military insurance Veterans Health Admin. Pregnant/post-partum Other funding sources: Women Other public funds Residential setting for patients & their children Other funds Size of Program: Level of care: Men # of admissions/last fiscal year ASAM-PPC-2R (Addiction): DUI/DWI Capacity (highest # servable) I. Outpatient Criminal justice clients Average length of stay (in days) II. IOP/Partial Hospital Adult General 112

118 Planned length of stay (in days) III. Residential/Inpatient # of unduplicated clients/year IV. Medically Managed Intensive Inpatient (Hospital) OMT: Opioid Maintenance D: Detoxification Mental Health: Outpatient Partial hospital/day program Inpatient DDCMHT assessment sources 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; Site tour. Total # of sources used: 113

119 DUAL DIAGNOSIS CAPABILITY IN MENTAL HEALTH TREATMENT (DDCMHT) VERSION 4.0 RATING SCALE 1 MHOS I. PROGRAM STRUCTURE IA. Primary focus of Mental health only. agency as stated in the mission statement (If program has mission, consider program mission). IB. Organizational Permits only mental certification and health treatment. licensure. IC. Coordination and collaboration with addiction services. No document of formal coordination or collaboration. Meets the SAMHSA definition of minimal Coordination. 2 3 DDC Has no actual barrier, but staff report there to be certification or licensure barriers. Vague, undocumented, or informal relationship with addiction agency, or consulting with a staff member from that agency. Meets the SAMHSA definition of Consultation. Primary focus is mental health, co-occurring disorders are treated. Has no barrier to providing addiction treatment or treating cooccurring disorders within the context of mental health treatment. Formalized and documented coordination or collaboration with addiction agency. Meets the SAMHSA definition of Collaboration. 4 5 DDE Formalized coordination and collaboration, and the availability of case management staff, or staff exchange programs (variably used). Meets the SAMHSA definition of Collaboration and has some informal components consistent with Integration. Primary focus on persons with cooccurring disorders. Is certified and/or licensed to provide both. Most services are integrated within the existing program, or routine use of case management staff or staff exchange programs. Meets the SAMHSA definition of Integration. ID. Financial incentives. Can only bill for mental health treatments or bill for persons with mental health disorders. Could bill for either service type if mental health disorder is primary, but staff report there to be barriers. OR- Partial reimbursement for addiction services available. Can bill for either service type, however, a mental health disorder must be primary. Can bill for addiction or mental health treatments, or their combination and/or integration. 114

120 II. PROGRAM MILIEU IIA. Routine expectation of and welcome to treatment for both disorders. IIB. Display and distribution of literature and patient educational materials. 1 MHOS Program expects mental health disorders only, refers or deflects persons with substance use disorders or symptoms. Mental health or peer support only. III. CLINICAL PROCESS: ASSESSMENT IIIA. Routine Pre-admission screening screening methods for based on patient selfreport. Decision based substance use. on clinician inference from patient presentation or history. IIIB. Routine assessment if screened positive for substance use. Assessment for substance use disorders is not recorded in records. 2 3 DDC Documented to expect mental health disorders only (e.g., admission criteria, target population), but has informal procedure to allow some persons with substance use disorders to be admitted. Available for both disorders but not routinely offered or formally available. Pre-admission screening for substance use and treatment history prior to admission. Assessment for substance use disorders occurs for some patients, but is not routine or is variable by clinician. Focus is on mental health disorders, but accepts substance use disorders by routine and if mild and relatively stable as reflected in program documentation. Routinely available for both mental health and substance use disorders in waiting areas, patient orientation materials and family visits, but distribution is less for substance use disorders. Routine set of standard interview questions for substance use using generic framework (e.g., ASAM-PPC Dim. I & V, LOCUS Dim. III) or Biopsychosocial data collection. Assessment for substance use disorders is present, formal, standardized, and documented in 50-69% of the records. Program formally defined like DDC but clinicians and program informally expect and treat co-occurring disorders regardless of severity, not well documented. Routinely available for both mental health and substance use disorders with equivalent distribution. 4 5 DDE Screen for substance use using standardized or formal instruments with established psychometric properties. Assessment for substance use disorders is present, formal, standardized, and documented in 70-89% of the records. Clinicians and program expect and treat cooccurring disorders regardless of severity, well documented. Routinely and equivalently available for both disorders and for the interaction between mental health and substance use disorders. Screen using standardized or formal instruments for both mental health and substance use disorders with established psychometric properties. Assessment for substance use disorders is formal, standardized, and integrated with assessment for mental health disorders, and documented in at least 90% of the records. 115

121 IIIC. Mental health and substance use diagnoses made and documented. IIID. Mental health and substance use history reflected in medical record. IIIE. Program acceptance based on substance use disorder symptom acuity: low, moderate, high. IIIF. Program acceptance based on severity and persistence of substance use disability: low, moderate, high. IIIG. Stage-wise assessment. 1 MHOS Substance use diagnoses are neither made nor recorded in records. Collection of mental health disorder history only. Admits persons with no to low acuity. Admits persons in program with no to low severity and persistence of substance use disability. Not assessed or documented. 2 3 DDC Substance use diagnostic impressions or past treatment records are present in records but the program does not have a routine process for making and documenting substance use diagnoses. Standard form collects mental health disorder history only. Substance use disorder history collected inconsistently. Assessed and documented variably by individual clinician. The program has a mechanism for providing diagnostic services in a timely manner. Substance use diagnoses are documented in 50-69% of the records. Routine documentation of both mental health and substance use disorder history in record in narrative section. Admits persons in program with low to moderate acuity, but who are primarily stable. Admits persons in program with low to moderate severity and persistence of substance use disability. Clinician assessed and routinely documented, focused on mental health motivation. 4 5 DDE The program has a Comprehensive mechanism for providing diagnostic services are routine, timely diagnostic provided in a timely services. Substance use manner. Substance use diagnoses are diagnoses are documented in 70-89% documented in at least of the records. 90% of the records. Specific section in record dedicated to history and chronology of both disorders. Formal measure used and routinely documented but focusing on mental health motivation only. Specific section in record devoted to history and chronology of both disorders and the interaction between them is examined temporally. Admits persons in program with moderate to high acuity, including those unstable in their substance use disorder. Admits persons in program with moderate to high severity and persistence of substance use disability. Formal measure used and routinely documented, focus on both substance use and mental health motivation. 116

122 1 MHOS IV. CLINICAL PROCESS: TREATMENT IVA. Treatment plans. Address mental health only (addiction not listed). IVB. Assess and monitor interactive courses of both disorders. IVC. Procedures for intoxicated/high patients, relapse, withdrawal, or active users. IVD. Stage-wise treatment. No documentation of progress with substance use disorders. No guidelines conveyed in any manner. Not assessed or explicit in treatment plan. Variable by individual clinician, i.e., plans vaguely or only sometimes address cooccurring substance use disorders. Variable reports of progress on substance use disorder by individual clinicians. Verbally conveyed inhouse guidelines. Stage of change or motivation documented variably by individual clinician in treatment plan. 2 3 DDC Plans routinely address both disorders although mental health disorders addressed as primary, substance use disorders as secondary with generic interventions. Routine clinical focus in narrative (treatment plan review or progress note) on substance use disorder change; description tends to be generic. Documented guidelines: referral or collaborations (to local addiction agency, detox unit, or emergency department). Stage of change or motivation routinely incorporated into individualized plan, but no specific stage-wise treatments. 4 5 DDE Plans routinely address substance use and mental health disorders; equivalent focus on both disorders; some individualized detail is variably observed. Treatment monitoring and documentation reflecting equivalent indepth focus on both disorders is available but variably used. Variable use of documented guidelines, formal risk assessment tools and advance directives for mental health crisis and substance use relapse. Stage of change or motivation routinely incorporated into individualized plan; general awareness of adjusting treatments by mental health stage or motivation only. Plans routinely address both disorders equivalently and in specific detail; interventions in addition to abstinence are used to address substance use disorder. Treatment monitoring and documentation routinely reflects clear, detailed, and systematic focus on change in both substance use and mental health disorders. Routine capability, or a process to ascertain risk with ongoing use of substances and/or severity of mental health symptoms; maintain in program unless alternative placement (i.e., detox, commitment) is warranted. Stage of change or motivation routinely incorporated into individualized plan; formally prescribed and delivered stage-wise treatments for both substance use and mental health disorders. 117

123 IVE. Policies and procedures for evaluation, management, monitoring and compliance for/of medications for substance use disorders. IVF. Specialized interventions with substance use disorders content. IVG. Education about substance use disorders, treatment, and interaction with mental health disorders. 1 MHOS Patients with active substance use routinely not accepted. No capacities to monitor, guide prescribing, or provide medications for substance use disorders during treatment. Not addressed in program content. Not offered. 2 3 DDC Certain types of medication for substance use disorders are not prescribed. Some capacity to monitor medications for substance use disorders. Based on judgment by individual clinician; variable penetration into routine services. Generic content, offered variably or by clinician judgment. Some types of medication for substance use disorders are routinely available. Present, coordinated policies regarding medication for substance use disorders. Some access to prescriber for medications and policies to guide prescribing are provided. Monitoring of the medication is largely provided by the prescriber. In program format as generalized intervention with penetration into routine services. Routine clinician adaptation of an evidence-based mental health treatment. Generic content, routinely delivered in individual and/or group formats. 4 5 DDE Clear standards and routine regarding medication for substance use disorders for medication prescriber who is also a staff member. Routine access to prescriber and guidelines for prescribing in place. The prescriber may periodically consult with other staff regarding medication plan and recruit other staff to assist with medication monitoring. Some specialized interventions by specifically trained clinicians in addition to routine generalized interventions. Specific content for specific co-morbidities; variably offered in individual and/or group formats. All types of medication for substance use disorders are available. Clear standards and routine for medication prescriber who is also a staff member. Full access to prescriber and guidelines for prescribing in place. The prescriber is on the treatment team and the entire team can assist with monitoring. Routine substance use disorder management groups; individual therapies focused on specific disorders; systematic adaptation of evidence-based addiction treatment (e.g., motivational interviewing, relapse prevention); or use of integrated evidencebased practices. Specific content for specific co-morbidities; routinely offered in individual and/or group formats. 118

124 119

125 IVH. Family education and support. IVI. Specialized interventions to facilitate use of peer support groups in planning or during treatment. 1 MHOS For mental health disorders only, or no family education at all. No interventions made to facilitate use of either addiction or mental health peer support. Variably or by clinician judgment. 2 3 DDC Used variably or infrequently by individual clinicians for individual patients, mostly for facilitation to mental health peer support groups. Substance use disorders routinely but informally incorporated into family education or support sessions. Available as needed. Generic format on site, but no specific or intentional facilitation based on substance use disorders. More routine facilitation to mental health peer support groups (e.g., NAMI, Procovery). 4 5 DDE Generic family group on site on substance use and mental health disorders, variably offered. Structured group with more routine accessibility. Variable facilitation targeting specific cooccurring needs, intended to engage patients in mental health peer support groups or groups specific to both disorders (e.g., DRA, DTR). Routine and systematic co-occurring disorder family group integrated into standard program format. Accessed by families of the majority of patients with cooccurring disorders. Routine facilitation targeting specific cooccurring needs, intended to engage patients in mental health peer support groups or groups specific to both disorders (e.g., DRA, DTR). IVJ. Availability of peer recovery supports for patients with cooccurring disorders. Not present, or if present not recommended. Off site, recommended variably. Off site and facilitated with contact persons or informal matching with peer supports in the community, some cooccurring focus. Off site, integrated into plan, and routinely documented with cooccurring focus. On site, facilitated and integrated into program (e.g., alumni groups); routinely used and documented with cooccurring focus. V. CONTINUITY OF CARE VA. Co-occurring Not addressed. disorder addressed in discharge planning process. Variably addressed by individual clinicians. Co-occurring disorder systematically addressed as secondary in planning process for off site referral. Some capacity (less than 80% of the time) to plan for integrated follow-up, i.e., equivalently address both substance use and mental health disorders as a priority. Both disorders seen as primary, with confirmed plans for on site followup, or documented arrangements for off site follow-up; at least 80% of the time. VB. Capacity to maintain treatment continuity. No mechanism for managing ongoing care of substance use disorder needs when mental health treatment program is completed. No formal protocol to manage substance use disorder needs once program is completed, but some individual clinicians may provide extended care until appropriate linkage takes place; variable documentation. No formal protocol to manage substance use disorder needs once program is completed, but when indicated, most individual clinicians provide extended care until appropriate linkage takes place. Routine documentation. Formal protocol to manage substance use disorder needs indefinitely, but variable documentation that this is routinely practiced, typically within the same program or agency. Formal protocol to manage substance use disorder needs indefinitely and consistent documentation that this is routinely practiced, typically within the same program or agency. 120

126 VC. Focus on ongoing recovery issues for both disorders. VD. Specialized interventions to facilitate use of community-based peer support groups during discharge planning. VE. Sufficient supply and compliance plan for medications for substance use disorders (see IVE) are documented. VI. STAFFING VIA. Psychiatrist or other physician or prescriber of medications for substance use disorders. 1 MHOS Not observed. No interventions made to facilitate use of either addiction or mental health peer support groups upon discharge. No medications in plan. No formal relationship with a prescriber for this program. Individual clinician determined. 2 3 DDC Used variably or infrequently by individual clinicians for individual patients, mostly for facilitation to mental health peer support groups upon discharge. Variable or undocumented availability of 30-day or supply to next appointment off site. Consultant or contractor off site. Routine focus is on recovery from mental health disorders, addiction viewed as potential relapse issue only. Generic, but no specific or intentional facilitation based on substance use disorders. More routine facilitation to mental health peer support groups (e.g., NAMI, Procovery) upon discharge. Routine 30-day or supply to next appointment off site. Prescription and confirmed appointment documented. Consultant or contractor on site. 4 5 DDE Routine focus on addiction recovery and mental health management and recovery, both seen as primary and ongoing. Assertive linkages and interventions routinely made targeting specific co-occurring needs to facilitate use of mental health peer support groups or groups specific to both disorders (e.g., DRA, DTR) upon discharge. Assertive linkages and interventions variably made targeting specific co-occurring needs to facilitate use of mental health peer support groups or groups specific to both disorders (e.g., DRA, DTR) upon discharge. Maintains medication management in program/agency until admission to next level of care at different provider (e.g., days). Prescription and confirmed admission documented. Staff member, present on site for clinical matters only. Maintains medication management in program with provider. Staff member, present on site for clinical, supervision, treatment team, and/or administration. VIB. On site clinical staff members with substance abuse licensure, certification, competency, or Program has no staff who are licensed/ certified as substance abuse professionals or have substantial 1-24% of clinical staff are licensed/certified substance abuse professionals or have substantial experience 25-33% of clinical staff are licensed/certified substance abuse professionals or have substantial experience 34-49% of clinical staff are licensed/certified substance abuse professionals or have substantial experience 50% or more of clinical staff are licensed/ certified substance abuse professionals or have substantial experience 121

127 substantive experience. experience sufficient to establish competence in addiction treatment. sufficient to establish competence in addiction treatment. sufficient to establish competence in addiction treatment. sufficient to establish competence in addiction treatment. sufficient to establish competence in addiction treatment. VIC. Access to addiction clinical supervision or consultation. VID. Case review, staffing or utilization review procedures emphasize and support co-occurring disorder treatment. 1 MHOS No access. Not conducted. 2 3 DDC Consultant or contractor off site, variably provided. Variable, by off site consultant, undocumented. Provided as needed or variably on site by consultant, contractor or staff member. Documented, on site, and as needed coverage of co-occurring issues. Routinely provided on site by staff member. 4 5 DDE Documented, routine, but not systematic coverage of co-occurring issues. Routinely provided on site by staff member and focuses on in-depth learning. Documented, routine and systematic coverage of co-occurring issues. VIE. Peer/Alumni supports are available with co-occurring disorders. VII. TRAINING VIIA. All staff members have basic training in attitudes, prevalence, common signs and symptoms, detection and triage for co-occurring disorders. Not available. No staff have basic training (0% trained). Available, with cooccurring disorders, but as part of the community. Variably referred by individual clinicians. Variably trained, no systematic agency training plan or individual staff member election (1-24% of staff trained). Available, with cooccurring disorders, but as part of the community. Routine referrals made thru clinician relationships or more formal connections such as peer support service groups (e.g., AA Hospital and Institutional committees or NAMI). Certain staff trained, encouraged by management and with systematic training plan (25-50% of staff trained). Available on site, with co-occurring disorders, either as paid staff, volunteers, or program alumni. Variable referrals made. Many staff trained and monitored by agency strategic training plan (51-79% of staff trained). Available on site, with co-occurring disorders, either as paid staff, volunteers, or program alumni. Routine referrals made. Most staff trained and periodically monitored by agency strategic training plan (80% or more of staff trained). VIIB. Clinical staff members have advanced specialized training in No clinical staff have advanced training (0% trained). Variably trained, no systematic agency training plan or Certain staff trained, encouraged by management and with Many staff trained and monitored by agency strategic training plan Most staff trained and periodically monitored by agency strategic 122

128 integrated psychosocial or pharmacological treatment of persons with co-occurring disorders. individual staff member election (1-24% of clinical staff trained). systematic training plan (25-50% of clinical staff trained). (51-79% of clinical staff trained). training plan (80% or more of clinical staff trained). 123

129 DUAL DIAGNOSIS CAPABILITY IN MENTAL HEALTH TREATMENT (DDCMHT) VERSION 4.0 SCORING SUMMARY I. Program Structure E. F. G. H. Sum Total = /4 = SCORE II. Program Milieu C. D. Sum Total = /2 = SCORE III. Clinical Process: Assessment H. I. J. K. L. M. N. Sum Total = /7 = SCORE IV. Clinical Process: Treatment K. L. M. N. O. P. Q. R. S. T. Sum Total = /10 = SCORE DDCMHT INDE PROGRAM CATEGORY: SCALE METHOD 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 ( ) DDCMHT INDE PROGRAM CATEGORY: CRITERION METHOD % CRITERIA MET FOR MHOS (# of 1 or > /35): _100% % CRITERIA MET FOR DDC (# of 3 or > scores/35): % CRITERIA MET FOR DDE (# of 5 scores/35): V. Continuity of Care F. G. H. I. J. Sum Total = /5 = SCORE VI. Staffing F. G. H. I. J. Sum Total = /5 = SCORE VII. Training C. D. Sum Total = /2 = SCORE HIGHEST LEVEL OF DD CAPABILITY (80% or more): 124

130 Attachment G: Integrated Treatment Fidelity Scale-Outpatient 2009 SAMHSA IDDT Toolkit 1. Multidisciplinary team: Case managers, psychiatrist, nurses, residential staff, employment specialists work collaboratively on mental health treatment team SCORE: 2. Integrated treatment specialist: Integrated treatment specialist work collaboratively with the multidisciplinary treatment team, modeling integrated treatment skills and training other staff in evidence-based practice principles and practice SCORE: 3. Stage-wise interventions: All services are consistent with and determined by each consumer s stage of treatment engagement, persuasion, active treatment, relapse prevention) % - 40% of consumers 41% - 60% of 61% -79% of receive care consumers receive consumers from a multidisciplinary care from a receive care team multidiscipli-nary from a team multidisciplinary team < 20% of clients receive care from multidisciplinary team (i.e., most care follows a brokered case management or traditional outpatient approach) OR Cannot rate due to no fit No integrated treatment specialist connected with agency OR Cannot rate due to no fit 20% of interventions are consistent with consumer s stage of treatment OR Cannot rate due to no fit Consumers with cooccurring disorders are referred to a separate Integrated Treatment program within the agency (for example, referred to integrated treatment specialists) 21%- 40% of interventions are consistent with consumer s stage of treatment Integrated treatment specialists serve as consultants to treatment teams, but are not fully integrated; attend some meetings; may be involved in treatment planning but not systematically 41%- 60% of interventions are consistent with consumer s stage of treatment Integrated treatment specialists are assigned to treatment teams, but are not fully integrated; attend some meetings; may be involved in treatment planning but not systematically 61% - 79% of interventions are consistent with consumer s stage of treatment >80% of consumers receive care from a fully multidisciplinary team with a strong emphasis on accessing a broad range of services and excellent communication among all disciplines Integrated treatment specialists are fully integrated members of the treatment team, attend all team meetings, are involved in treatment planning, model and train other staff in Integrated Treatment for Co-Occurring Disorders >80% of interventions are consistent with client s stage of recovery SCORE: 125

131 4. Access comprehensive services Consumers in the Integrated Treatment program have access to comprehensive services including the following: Residential services Supported employment Family interventions Illness management and recovery Assertive community treatment services are 3 services are 4 services are provided by the provided by the provided by the agency and agency and service provider consumers have consumers have and IDDT genuine access to genuine access to clients have these services these services genuine access to these services Fewer than 2 services are provided by the agency or consumers do not have genuine access to these services OR Cannot rate due to no fit All 5 services are provided by the agency and consumers have genuine access to these services SCORE: 5. Time-unlimited services Consumers in the Integrated Treatment program are treated on a time-unlimited basis with intensity modified according to each consumer s needs. SCORE: 6. Outreach: Integrated treatment specialists demonstrate consistently Services are provided on a timeunlimited basis 20% or less of the time (for example, consumers are closed out of most services after a defined period of time), OR Cannot rate due to no fit. Integrated treatment specialists are passive in recruitment and reengagement; almost never use outreach Services are provided on a timeunlimited basis 21%-40% of the time Integrated treatment specialists make initial attempts to engage, but generally focus efforts on most Services are provided on a timeunlimited basis 41%- 60% of the time Integrated treatment specialists try outreach mechanisms only as convenient Services are provided on a time-unlimited basis 61%-79% of the time Integrated treatment specialists usually have plan for engagement and Services are provided on a timeunlimited basis with intensity modified according to each consumer s needs >80% of the time Integrated treatment specialists demonstrate consistently well-thought out out-reach strategies and connect 126

132 well-thought out outreach strategies and connect consumers to community mechanisms, OR Cannot rate due to no fit motivated consumers use most available outreach mechanisms consumers to community services, whenever appropriate, to keep consumers engaged. ser-vices, whenever appropriate, to keep consumers engaged in the Integrated Treatment program. SCORE: 127

133 7. Motivational interventions: All interactions with consumers in the Integrated Treatment program are based on motivational interventions that include the following: Expressing empathy Developing discrepancy Avoiding argumentation Rolling with resistance Instilling self-efficacy and hope Some integrated Most integrated All integrated treatment specialists treatment specialists treatment understand understand specialists motivational motivational understand interventions, and interventions, and motivational 21%- 40% of 41%- 60% of interventions interactions with interactions with and 61%- 79% consumers are based consumers are based of interactions on motivational on motivational with consumers approaches approaches are based on motiva-tional approaches Integrated treatment specialists do not understand motivational interventions, <20% of interactions with consumers are based on motivational approaches, OR Cannot rate due to no fit All integrated treatment specialists understand motivational interventions and >80% of interactions with clients are based on motivational approaches SCORE: 8. Substance abuse counseling: Consumers who are in the active treatment or relapse prevention stages receive substance abuse counseling that includes: How to manage cues to use and consequences of use Relapse prevention strategies Drug and alcohol refusal skills training Problem-solving skills training to avoid high-risk situations Coping skills and social skills training Challenging consumers Integrated treatment specialists do not understand basic substance abuse counseling principles and 20% of consumers in active treatment stage or relapse prevention stage receive substance abuse counseling OR Cannot rate due to no fit Some integrated treatment specialists understand basic substance abuse counseling principles and 21%- 40% of consumers in active treatment stage or relapse prevention stage receive substance abuse counseling Most integrated treatment specialists understand basic substance abuse counseling principles and 41%- 60% of consumers in active treatment stage or relapse prevention stage receive substance abuse counseling All integrated treatment specialist understand basic substance abuse counseling principles and 61% - 79% of consumers in active treatment stage or relapse prevention stage receive substance abuse counseling All integrated treatment specialists understand basic substance abuse counseling principles and >80% of consumers in active treatment stage or relapse prevention stage receive substance abuse counseling 128

134 beliefs about substance abuse SCORE: 129

135 9. Group treatment for cooccurring disorders: Consumers in the Integrated Treatment program are offered group treatment specifically designed to address both mental health and substance abuse problems % - 34% of 35% - 49% of 50% - 65% of Consumers regularly Consumers regularly Consumers attend group attend group regularly attend treatment treatment group treatment <20% of Consumers regularly attend group treatment, OR Cannot rate due to no fit >65% of Consumers regularly attend group treatment SCORE: 10. Family interventions for co-occurring disorders: With consumers permission, integrated treatment specialists involve consumers family (or other supporters), provide education about cooccurring disorders, offer coping skills training and support to reduce stress in the family, and promote collaboration with the treatment team Consumers are not asked for permission to involve family (or other supporters) or <20% of families (or other supporters) receive family interventions for cooccurring disorders OR Cannot rate due to no fit Consumers are asked for permission to involve family (or other supporters) and 20% - 34% of families (or other supporters) receive family interventions for co-occurring disorders Consumers are asked for permission to involve family (or other supporters) and 35% - 49% of families (or other supporters) receive family interventions for co-occurring disorders Consumers are asked for permission to involve family (or other supporters) and 50% - 65% of families (or significant others) receive family interventions for co-occurring disorders Consumers are asked for permission to involve family (or other supporters) and >65% of families (or significant others) receive family interventions for cooccurring disorders SCORE: 11. Alcohol and drug selfhelp groups: Consumers in the active treatment or relapse prevention stages attend self-help programs in the community <20% of consumers in the active treatment or relapse prevention stages attend self-help programs in the community OR - 20% - 34% of consumers in the active treatment or relapse prevention stages attend selfhelp programs in the community 35% - 49% of consumers in the active treatment or relapse prevention stages attend selfhelp programs in the community 50% - 65% of consumers in the active treatment or relapse prevention stages attend >65% of consumers in the active treatment or relapse prevention stages attend self-help programs in the community 130

136 SCORE: Cannot rate due to no fit self-help programs in the community 131

137 12. Pharmacological Treatment: Prescribers for Integrated Treatment program are trained in the evidence- based model and use the following strategies: Prescribe psychiatric medications despite active substance use Work closely with consumers and the treatment team Focus on increasing adherence to psychiatric medication Avoid prescribing medications that may be addictive Prescribe medications that help reduce addictive behavior SCORE: 13. Interventions to promote health: Integrated treatment specialists promote health by encouraging consumers with co-occurring disorders to do the following: Avoid high-risk behavior and situations that can lead to infectious diseases Prescribers use less than 2 of the strategies listed, OR Cannot rate due to no fit Approximately 2 of 5 Approximately 3 of 5 4 of 5 strategies strategies used strategies used used Integrated treatment specialists offer no interventions to promote health, OR Cannot rate due to no fit Integrated treatment specialists may have some knowledge of reducing negative consequences of substance abuse, but rarely use concepts Less than half of all consumers receive services to promote health; integrated treatment specialists use concepts unsystematically 50%- 79% of consumers receive services to promote health; all integrated treatment special-ists are well versed in techniques to reduce negative Evidence that all 5 strategies used; medi-cations are prescribed despite active sub-stance use, prescribers receive pertinent input from the treatment team about medication decisions, use strate-gies to maximize adherence to psychiatric medications avoid pre-scribing medications that are addictive and offer medications known to be effective for reducing addictive behavior >80% of consumers receive services to promote health; all integrated treatment specialists are well versed in techniques to reduce negative consequences of substance abuse 132

138 Find safe housing Practice proper diet and exercise consequences of substance abuse SCORE: 133

139 14. Secondary Interventions for nonresponders: The Integrated Treatment program has a protocol to identify consumers who do not respond to basic treatment to basic treatment for co-occurring disorders to evaluate them, and to link them to appropriate secondary interventions SCORE: %- 40% of nonresponders Program has protocol Program has are and 41%- 60% of protocol for evaluated and non-responders are identifying referred for evaluated and nonresponders secondary referred for and 61%- 79% interventions secondary of nonresponders OR interventions are Secondary OR evaluated and interventions, are not No formal method to referred for systematically identify secondary offered to available nonresponders interventions nonresponders 20% of nonresponders are evaluated and referred for secondary interventions OR There is no recognition of a need for secondary interventions for nonresponders OR Cannot rate due to no fit Program has protocol to identify nonresponders and >80% of nonresponders are evaluated and referred for secondary interventions 2009 SAMHSA IDDT Toolkit 134

140 Attachment H: Co-Occurring Assessment Guideline Connecticut Department of Mental Health and Addiction Services Introduction This document provides guidance on the important elements to include in the assessment process to ensure that it is responsive to the needs of individuals with co-occurring mental health and substance use disorders. Assessments need to examine all factors necessary to establish a mental health and substance use diagnosis and to determine the level of care and nature of treatment to ensure the best outcomes. In addition, assessments must be completed by persons who have knowledge of the characteristics and nature of substance use and mental health disorders, how situational factors can affect an assessment and of stages of change/motivational factors. Definition of Assessment Assessment gathers information and engages in a process with the client that enables the provider to establish (or rule out) the presence or absence of a co-occurring disorder. Determines the client s readiness for change, identifies client strengths or problem areas that may affect the processes of treatment and recovery, and engages the client in the development of an appropriate treatment relationship. (SAMHSA COCE, Overview Paper 2) Assessment Process The assessment process includes the following general steps: 1. Engage the client 2. Upon receipt of appropriate client authorization(s), identify and contact collaterals (family, friends, other treatment providers) to gather additional information 3. Screen for and detect COD 4. Determine severity of mental and substance use disorders 5. Determine appropriate care settings (e.g., inpatient, outpatient, day-treatment) 6. Determine diagnoses 7. Determine disability and functional impairment 8. Identify intrinsic and extrinsic (environmental) strengths and supports for each functional domain or target behavior 9. Identify cultural, linguistic, and disability related needs, supports and assets. 10. Identify additional problem areas to address (e.g., physical health, housing, vocational, legal involvement, educational, social, spiritual, cognitive, etc.) and corresponding assets, supports, or opportunities. 11. Determine readiness for change 12. Identify client s expressed hopes, preferences, desires regarding life goals, outcomes for treatment. 135

141 13. Determine client s wishes as to others they may want involved in their treatment & support process. 14. Plan treatment (adapted from SAMHSA COCE, Overview Paper 2) Guiding Principles of Assessment as it relates to People with Co-Occurring Disorders Assessment: 1. Defines the nature of a problem and develops specific treatment recommendations. 2. Is an ongoing process that is repeated to detect changes in a client s status and needs. 3. The use of traditional standard tools should be individually selected to be responsive to client needs and history. 4. Recognizes that all disorders are primary and each proceeds independently. 5. Should gather information useful in developing recovery plans including: a. Information concerning relationships, life experiences, health challenges, financial and housing needs, strengths, resources (Recovery Capital) and other background information. b. Substance use and mental health history including diagnosis, severity, treatment and family history. c. Periods of time and /or situations when the identified problems are not present or are markedly less severe and the corresponding context or coping factors present during those times. 6. Is person centered and sensitive to culture, gender, sexual orientation, chronological and developmental age, level of literacy, and history of trauma. 7. Ascertains nature and severity of substance use disorder(s) and mental health problem(s) to determine appropriate level of care 8. Realizes that diagnoses and severity of disorders change and that gathering information from clients that includes a specific historical timeline of symptoms and diagnoses is essential. 9. Determines stage of change for each problem and motivation for change, and identify external contingencies that might help to promote treatment adherence. 10. Takes into consideration the interactive nature of Co-occurring Disorders a. that substance use can be a catalyst for mental illness and can increase the severity of symptoms b. that mental illness can be a catalyst for substance use and can lead to increased use and polysubstance use 11. Considers the situational factors that may be present and may make it difficult to establish if a person has co-occurring disorders. Intoxication individual is intoxicated at the time of the assessment Withdrawal individual is experiencing the physical and mental symptoms of withdrawal 136

142 Substance induced disorders effects of substances mimic mental health symptoms such as depression, anxiety and hallucinations Physical health issues and status including: Medical problems Medications Aging process Pregnancy Motivation factors influencing an individual s willingness to accurately answer assessment questions for both mental health and substance use Stress related to family, employment, financial and other problems 12. Considers a person s history of trauma including physical and sexual violence and identifies symptoms that may constitute coping mechanisms. 13. Recognizes that therapeutic rapport is a fluid, relational process. Client disclosure may unfold overtime necessitating the need to revisit some assessment topics. A client may initially be reluctant to discuss or may minimize trauma experiences, sexual or gender identification issues, or their victimization of others, for instance Characteristics of Assessment Process as it relates to People with Co-Occurring Disorders 1. Individuals conducting the assessment should, at minimum, possess the following competencies: Knowledge of the substance use and mental health diagnostic categories in the DSM IV Ability to determine severity of disorders Knowledge of current street names of the various drugs Capable of assessing stage of change for both disorders Ability to complete a functional assessment The necessary skills to document mental health and substance use disorder diagnoses Basic knowledge of physical health issues and medications used to treat such conditions Knowledge leading to an understanding of differences among feelings, symptoms and disorders 2. The five basic principles of Motivational Interviewing should guide all interactions related to assessment: expressing empathy avoiding argument supporting self-efficacy rolling with resistance 137

143 developing discrepancy 3. Assessments must include consideration of motivational factors and stage of change, their impact on the assessment and to gather information to plan effective treatment plans: Determine if someone is motivated to change as opposed to motivated to seek/accept help. Consider whether the client is in the Precontemplation, Contemplation, Preparation or Action Stage of Change for each target behavior (i.e. treatment, employment, social affiliations) 4. Co-Occurring disorders are present in many different combinations. The assessment process must include the capacity to determine the level of substance dependence and the severity of the mental health disorders(s) present. This information should also be used to determine the appropriate level of care. 5. Individuals should develop a personal Recovery Resource Inventory. This includes examining the strengths and supports a person has at his or her disposal. 138

144 Sources: COCE Overview Paper #2 Screening, Assessment, and Treatment Planning for Persons with Co-Occurring Disorders, 2006 Connecticut DMHAS: Competencies for Providing Services to Individuals with Co-Occurring Mental Health and Substance Use Disorders Version 1.1, 2008 CSAT Treatment Improvement Protocol #42, 2005 Hazelden Co-Occurring Disorders Program: Screening and Assessment, 2008 Standardized tools tailored to the needs of the client are recommended. These include, but are not limited to the following tools: Addiction Severity Index (ASI) Alcohol Use Disorder and Associated Disabilities Interview Scale (AUDADIS) American Society of Addiction Medicine Patient Placement Criteria 2nd Edition Revised (ASM PPC-2R) Composite International Diagnostic Interview (CIDI) Global Appraisal of Individual Needs (GAIN) Hamilton Anxiety Schedule Hamilton Depression Schedule Patient Health Questionnaire 9 (PHQ-9) Psychiatric Research Interview for Substance Use and Mental Disorders (PRISM) Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) Structured Clinical Interview for DSM-IV (SCID) University of Rhode Island Change Assessment Scale (URICA) Zung Self-Rating Depression Scale 139

145 Attachment I: Integrated Treatment Curricula Co-Occurring Disorders Treatment Manual and Workbook University of South Florida. Free downloads: The Basics A Curriculum for Co-Occurring Psychiatric and Substance Disorders Second Edition Rhonda McKillip, M.Ed., LMHC, MAC, CCDCIII, CDP. Two volumes. Approximately $100 and available at: Hazelden Co-occurring Disorders Program Integrated Services for Substance Use and Mental Health Problems Faculty from the Dartmouth Medical School, 6 modules and DVD; approximately $1300, but individual modules and DVD are sold separately. Available at: Co-Occurring Disorders Workbook Recovery Strategies for Substance Use and Mental Health Disorders Third Edition Dennis C. Daley, MSW. Approximately $25 and available at: Overcoming Addictions Skills Training for People with Schizophrenia Lisa J. Roberts, Andrew Shaner, and Thad A. Eckman. Book is approximately $25 and available at (or major bookstore websites) and accompanying VHS tape [ISBN#: (8)] available by calling W.W. Norton & Company, Inc. at Intervention for Alcohol, Cannabis and Amphetamine Use among People with a Psychotic Illness Amanda Baker, Sandra Bucci, & Frances Kay-Lambkin. Free download: 140

146 Attachment J: Employment Workshop/Database Document Name of company: Dunn County Skills/Needs Match Directory Project Employer/Community Service Site Database Address, phone, , office hours: Product or service(s) provided: Types of positions filled (i.e. cashier, maintenance worker, lab technician) Work environment expected? If interested in hiring criminal justice participants, what charges will you not accept (i.e. check fraud, theft, domestic abuse, etc.)? Why should present and potential employees be excited to work for you or your company? Requirements of potential employees (i.e. personality traits, job skills): What does your application process consist of? 141

147 Please check one: Interested in hiring criminal justice participants and would like to be included in database, which will be made available to the participants and the general public. (Note: Database will eventually be included on the Dunn County Criminal Justice Collaboration Council Website for viewing at Interested in being part of database and community service site list (sites where criminal justice participants can complete community service hours). Not interested at this time but would like to be added to the community service site list. Not interested at this time but would like more information. Not interested at this time but will consider being added to the database in the future. Not interested at this time. Please fill in: Would like information (i.e. brochure) to share with other companies: yes no thanks Thank you for completing this form. 142

148 Attachment K: SUPPORTED EMPLOYMENT FIDELITY SCALE* 1/7/08 Rater: Site: Date: Total Score: Directions: Circle one anchor number for each criterion. Criterion Data Anchor Source** Staffing 1. Caseload size: Employment specialists MIS, 1=Ratio of 41 or more clients per employment specialist. have individual employment caseloads. The DOC, INT maximum caseload for any full-time employment 2= Ratio of clients per employment specialist. specialist is 20 or fewer clients. 3= Ratio of clients per employment specialist. 4= Ratio of clients per employment specialist. 5= Ratio of 20 or fewer clients per employment specialist. 2. Employment services staff: Employment MIS, DOC 1= Employment specialists provide employment services specialists provide only employment INT less than 60% of the time. services. 2= Employment specialists provide employment services 60-74% of the time. 3= Employment specialists provide employment services 75-89% of the time. 4= Employment specialists provide employment services 90-95% of the time. 5= Employment specialists provide employment services 96% or more of the time. 143

149 3. Vocational generalists: Each employment MIS, DOC, 1= Employment specialist only provides vocational referral specialist carries out all phases of employment INT, OBS service to vendors and other programs. service, including intake, engagement, assessment, job placement, job coaching, and follow-along 2= Employment specialist maintains caseload but refers clients supports before step down to less intensive employment to other programs for vocational services. support from another MH practitioner. (Note: It is not expected that each employment specialist will provide 3= Employment specialist provides one to four phases of the employment benefits counseling to their clients. Referrals to a highly service (e.g. intake, engagement, assessment, job development, job trained benefits counselor are in keeping with high placement, job coaching, and follow along supports). fidelity, see Item # 1 in Services.) 4= Employment specialist provides five phases of employment service but not the entire service. 5= Employment specialist carries out all six phases of employment service (e.g. program intake, engagement, assessment, job development/job placement, job coaching, and follow-along supports). ORGANIZATION 1. Integration of rehabilitation with mental health MIS, DOC, 1= Employment specialists are part of a vocational program that functions treatment thru team assignment: Employment INT, OBS separately from the mental health treatment. specialists are part of up to 2 mental health treatment teams from which at least 90% of the employment specialist s caseload is comprised. 2= Employment specialists are attached to three or more mental health treatment teams. OR Clients are served by individual mental health practitioners who are not organized into teams. OR Employment specialists are attached to one or two teams from which less than 50% of the employment specialist s caseload is comprised. 3= Employment specialists are attached to one or two mental health treatment teams, from which at least 50-74% of the employment specialist s caseload is comprised. 4= Employment specialists are attached to one or two mental health treatment teams, from which at least 75-89% of the employment specialist s caseload is comprised. 5= Employment specialists are attached to one or two mental health 144

150 treatment teams, from which % of the employment specialist s caseload is comprised. 2. Integration of rehabilitation with mental health MIS, DOC 1= One or none is present. treatment thru frequent team member contact: INT, OBS Employment specialists actively participate in 2= Two are present weekly mental health treatment team meetings (not replaced by administrative meetings) that discuss 3= Three are present. individual clients and their employment goals with shared decision-making. Employment specialist s office 4= Four are present. is in close proximity to (or shared with) their mental health treatment team members. Documentation of 5= Five are present. mental health treatment and employment services are integrated in a single client chart. Employment specialists All five key components are present. help the team think about employment for people who haven t yet been referred to supported employment Employment specialist attends weekly mental health treatment team meetings. services. Employment specialist participates actively in treatment team meetings with shared decision-making. Employment services documentation (i.e., vocational assessment/profile, employment plan, progress notes) is integrated into client s mental health treatment record. Employment specialist s office is in close proximity to (or shared with) their mental health treatment team members. Employment specialist helps the team think about employment for people who haven t yet been referred to supported employment services. 3. Collaboration between employment specialists DOC, INT 1= Employment specialists and VR counselors have client-related contacts and Vocational Rehabilitation counselors: The OBS, ISP (phone, , in person) less than quarterly to discuss shared employment specialists and VR counselors have frequent clients and referrals. OR Employment specialists and VR counselors contact for the purpose of discussing shared clients do not communicate. and identifying potential referrals. 2= Employment specialists and VR counselors have client-related contacts (phone, , in person) at least quarterly to discuss shared clients and referrals. 3= Employment specialists and VR counselors have client-related contacts (phone, , in-person) monthly to discuss shared clients and referrals. 145

151 4= Employment specialists and VR counselors have scheduled, face-to-face meetings at least quarterly, OR have client-related contacts (phone, , in person) weekly to discuss shared clients and referrals. 5= Employment specialists and VR counselors have scheduled, face-toface meetings at least monthly and have client-related contacts (phone, , in person) weekly to discuss shared clients and referrals. 4. Vocational unit: At least 2 full-time employment MIS, INT, 1= Employment specialists are not part of a vocational unit. specialists and a team leader comprise the OBS employment unit. They have weekly client-based 2= Employment specialists have the same supervisor but do group supervision following the supported employment not meet as a group. They do not provide back-up services for each other s model in which strategies are identified and job leads caseload. are shared. They provide coverage for each other s caseload when needed. 3= Employment specialists have the same supervisor and discuss clients between each other on a weekly basis. They provide back-up services for each other s caseloads as needed. OR, If a program is in a rural area where employment specialists are geographically separate with one employment specialist at each site, the employment specialists meet 2-3 times monthly with their supervisor by teleconference. 4= At least 2 employment specialists and a team leader form an employment unit with 2-3 regularly scheduled meetings per month for client-based group supervision in which strategies are identified and job leads are shared and discuss clients between each other. They provide coverage for each other s caseloads when needed. OR, If a program is in a rural area where employment specialists are geographically separate with one employment specialist at each site, the employment specialists meet 2-3 times per month with their supervisor in person or by teleconference and mental health practitioners are available to help the employment specialist with activities such as taking someone to work or picking up job applications. 5= At least 2 full-time employment specialists and a team leader form an employment unit with weekly client-based group supervision based on the supported employment model in which strategies are identified and job leads are shared. They provide coverage for each other s caseloads when needed. 146

152 5. Role of employment supervisor: Supported MIS, INT, 1= One or none is present. employment unit is led by a supported employment DOC, OBS team leader. Employment specialists skills are 2= Two are present. developed and improved through outcome-based supervision. All five key roles of the employment 3= Three are present. supervisor are present. 4= Four are present. 5= Five are present. Five key roles of the employment supervisor: One full-time equivalent (FTE) supervisor is responsible for no more than 10 employment specialists. The supervisor does not have other supervisory responsibilities. (Program leaders supervising fewer than ten employment specialists may spend a percentage of time on other supervisory activities on a prorated basis. For example, an employment supervisor responsible for 4 employment specialists may be devoted to SE supervision half time.) Supervisor conducts weekly supported employment supervision designed to review client situations and identify new strategies and ideas to help clients in their work lives. Supervisor communicates with mental health treatment team leaders to ensure that services are integrated, to problem solve programmatic issues (such as referral process, or transfer of follow-along to mental health workers) and to be a champion for the value of work. Attends a meeting for each mental health treatment team on a quarterly basis. Supervisor accompanies employment specialists, who are new or having difficulty with job development, in the field monthly to improve skills by observing, modeling, and giving feedback on skills, e.g., meeting employers for job development. Supervisor reviews current client outcomes with employment specialists and sets goals to improve program performance at least quarterly. 147

153 6. Zero exclusion criteria: All clients interested in DOC, INT 1= There is a formal policy to exclude clients due to lack of job readiness working have access to supported employment OBS (e.g., substance abuse, history of violence, low level of functioning, etc.) services regardless of job readiness factors, substance by employment staff, case managers, or other practitioners. abuse, symptoms, history of violent behavior, cognition impairments, treatment non-adherence, and 2= Most clients are unable to access supported employment services due to personal presentation. These apply during supported perceived lack of job readiness (e.g., substance abuse, history of violence, low employment services too. Employment specialists offer level of functioning, etc.). to help with another job when one has ended, regardless of the reason that the job ended or number 3= Some clients are unable to access supported employment services due to of jobs held. If VR has screening criteria, the mental perceived lack of job readiness (e.g., substance abuse, history of violence, low health agency does not use them to exclude anybody. level of functioning, etc.). Clients are not screened out formally or informally. 4= No evidence of exclusion, formal or informal. Referrals are not solicited by a wide variety of sources. Employment specialists offer to help with another job when one has ended, regardless of the reason that the job ended or number of jobs held. 5= All clients interested in working have access to supported employment services. Mental health practitioners encourage clients to consider employment, and referrals for supported employment are solicited by many sources. Employment specialists offer to help with another job when one has ended, regardless of the reason that the job ended or number of jobs held. 7. Agency focus on competitive employment: DOC, INT, 1= One or none is present. Agency promotes competitive work through multiple OBS strategies. Agency intake includes questions 2= Two are present. about interest in employment. Agency displays written postings (e.g., brochures, bulletin boards, posters) 3= Three are present. about employment and supported employment services. The focus should be with the agency programs that 4= Four are present. provide services to adults with severe mental illness. Agency supports ways for clients to share work stories 5= Five are present. with other clients and staff. Agency measures rate of competitive employment and shares this information with Agency promotes competitive work through multiple strategies: agency leadership and staff. Agency intake includes questions about interest in employment. 148

154 Agency includes questions about interest in employment on all annual (or semiannual) assessment or treatment plan reviews. Agency displays written postings (e.g., brochures, bulletin boards, posters) about working and supported employment services, in lobby and other waiting areas. Agency supports ways for clients to share work stories with other clients and staff (e.g., agency-wide employment recognition events, in-service training, peer support groups, agency newsletter articles, invited speakers at client treatment groups, etc.) at least twice a year. Agency measures rate of competitive employment on at least a quarterly basis and shares outcomes with agency leadership and staff. 8. Executive team support for SE: Agency executive DOC, INT, 1= One is present. team members (e.g., CEO/Executive Director, Chief OBS Operating Officer, QA Director, Chief Financial Officer, 2= Two are present. Clinical Director, Medical Director, Human Resource Director) assist with supported employment 3= Three are present. implementation and sustainability. All five key components of executive team support are present. 4= Four are present. 5= Five are present. Executive Director and Clinical Director demonstrate knowledge regarding the principles of evidence-based supported employment. Agency QA process includes an explicit review of the SE program, or components of the program, at least every 6 months through the use of the Supported Employment Fidelity Scale or until achieving high fidelity, and at least yearly thereafter. Agency QA process uses the results of the fidelity assessment to improve SE implementation and sustainability. At least one member of the executive team actively participates at SE leadership team meetings (steering committee meetings) that occur at least every six months for high fidelity programs and at least quarterly for programs that have not yet achieved high fidelity. Steering committee is defined as a diverse group of stakeholders charged with reviewing fidelity, program implementation, and the service delivery 149

155 system. Committee develops written action plans aimed at developing or sustaining high fidelity services. The agency CEO/Executive Director communicates how SE services support the mission of the agency and articulates clear and specific goals for SE and/or competitive employment to all agency staff during the first six months and at least annually (i.e., SE kickoff, all-agency meetings, agency newsletters, etc.). This item is not delegated to another administrator. SE program leader shares information about EBP barriers and facilitators with the executive team (including the CEO) at least twice each year. The executive team helps the program leader identify and implement solutions to barriers. SERVICES 1. Work incentives planning: All clients are offered assistance DOC, INT 1= Work incentives planning is not readily available or easily accessible to most in obtaining comprehensive, individualized work OBS, ISP clients served by the agency. incentives planning before starting a new job and assistance accessing work incentives planning thereafter when making 2= Employment specialist gives client contact information about decisions about changes in work hours and pay. Work where to access information about work incentives planning. incentives planning includes SSA benefits, medical benefits, medication subsidies, housing subsidies, food stamps, spouse and 3= Employment specialist discusses with each client changes in benefits based on dependent children benefits, past job retirement benefits and any work status. other source of income. Clients are provided information and assistance about reporting earnings to SSA, housing 4= Employment specialist or other MH practitioner offer clients assistance in programs, VA programs, etc., depending on the person s obtaining comprehensive, individualized work incentives planning by a person benefits. trained in work incentives planning prior to client starting a job. 5= Employment specialist or other MH practitioner offer clients assistance in obtaining comprehensive, individualized work incentives planning by a specially trained work incentives planner prior to starting a job. They also facilitate access to work incentives planning when clients need to make decisions about changes in work hours and pay. Clients are provided information and assistance about reporting earnings to SSA, housing programs, etc., depending on the person s benefits. 150

156 2. Disclosure: Employment specialists provide DOC, INT 1= None is present. clients with accurate information and assist with OBS evaluating their choices to make an informed 2= One is present. decision regarding what is revealed to the employer about having a disability. 3= Two are present. 4= Three are present. 5= Four are present. Employment specialists do not require all clients to disclose their psychiatric disability at the work site in order to receive services. Employment specialists offer to discuss with clients the possible costs and benefits (pros and cons) of disclosure at the work site in advance of clients disclosing at the work site. Employment specialists describe how disclosure relates to requesting accommodations and the employment specialist s role communicating with the employer. Employment specialists discuss specific information to be disclosed (e.g., disclose receiving mental health treatment, or presence of a psychiatric disability, or difficulty with anxiety, or unemployed for a period of time, etc.) and offers examples of what could be said to employers. Employment specialists discuss disclosure on more than one occasion (e.g., if clients have not found employment after two months or if clients report difficulties on the job.) 3. Ongoing, work-based vocational assessment: DOC, INT, 1= Vocational evaluation is conducted prior to job placement with Initial vocational assessment occurs over 2-3 OBS, ISP emphasis on office-based assessments, standardized tests, intelligence sessions and is updated with information tests, work samples. from work experiences in competitive jobs. A vocational profile form that includes information 2= Vocational assessment may occur through a stepwise approach that about preferences, experiences, skills, current includes: prevocational work experiences (e.g., work units in a day adjustment, strengths, personal contacts, etc, is updated with program), volunteer jobs, or set aside jobs (e.g., NISH jobs agency-run 151

157 each new job experience. Aims at problem solving using environmental assessments and consideration of reasonable accommodations. Sources of information include the client, treatment team, clinical records, and with the client s permission, from family members and previous employers. businesses, sheltered workshop jobs, affirmative businesses, enclaves). 3= Employment specialists assist clients in finding competitive jobs directly without systematically reviewing interests, experiences, strengths, etc. and do not routinely analyze job loss (or job problems) for lessons learned. 4= Initial vocational assessment occurs over 2-3 sessions in which interests and strengths are explored. Employment specialists help clients learn from each job experience and also work with the treatment team to analyze job loss, job problems and job successes. They do not document these lessons learned in the vocational profile, OR The vocational profile is not updated on a regular basis. 5= Initial vocational assessment occurs over 2-3 sessions and information is documented on a vocational profile form that includes preferences, experiences, skills, current adjustment, strengths, personal contacts, etc. The vocational profile form is used to identify job types and work environments. It is updated with each new job experience. Aims at problem solving using environmental assessments and consideration of reasonable accommodations. Sources of information include the client, treatment team, clinical records, and with the client s permission, from family members and previous employers. Employment specialists help clients learn from each job experience and also work with the treatment team to analyze job loss, job problems and job successes. 4. Rapid job search for competitive job: Initial DOC, INT, 1= First face-to-face contact with an employer by the client or the employment employment assessment and first face-to-face OBS, ISP specialist about a competitive job is on average 271 days or more (> 9 mos.) employer contact by the client or the employment after program entry. specialist about a competitive job occurs within 30 days (one month) after program entry. 2= First face-to-face contact with an employer by the client or the employment specialist about a competitive job is on average between 151 and 270 days (5-9 mos.) after program entry. 3= First face-to-face contact with an employer by the client or the employment specialist about a competitive job is on average between 61 and 150 days (2-5 mos.) after program entry. 4= First face-to-face contact with an employer by the client or the employment specialist about a competitive job is on average between 31 and 60 days (1-2 mos.) after program entry. 152

158 5= The program tracks employer contacts and the first face-to-face contact with an employer by the client or the employment specialist about a competitive job is on average within 30 days (one month) after program entry. 5. Individualized job search: Employment specialists DOC, INT 1= Less than 25% of employer contacts by the employment specialist are based on make employer contacts aimed at making a good OBS, ISP job choices which reflect client s preferences, strengths, symptoms, etc. job match based on clients preferences (relating to rather than the job market. what each person enjoys and their personal goals) and needs (including experience, ability, 2= 25-49% of employer contacts by the employment specialist are based on job symptomatology, health, etc.) rather than the choices which reflect client s preferences, strengths, symptoms, etc., rather job market (i.e., those jobs that are readily available). than the job market. An individualized job search plan is developed and updated with information from the vocational 3= 50-74% of employer contacts by the employment specialist are based on job assessment/profile form and new job/educational choices which reflect client s preferences, strengths, symptoms, etc., rather experiences. than the job market. 4= 75-89% of employer contacts by the employment specialist are based on job choices which reflect client s preferences, strengths, symptoms, etc., rather than the job market and are consistent with the current employment plan. 5= Employment specialist makes employer contacts based on job choices which reflect client s preferences, strengths, symptoms, lessons learned from previous jobs etc., % of the time rather than the job market and are consistent with the current employment/job search plan. When clients have limited work experience, employment specialists provide information about a range of job options in the community. 6. Job development - Frequent employer contact: DOC, INT 1= Employment specialist makes less than 2 face-to-face employer contacts Each employment specialist makes at least that are client-specific per week. 6 face to-face employer contacts per week on behalf of clients looking for work. (Rate for each 2= Employment specialist makes 2 face-to-face employer contacts then calculate average and use the closest scale per week that are client-specific, OR Does not have a process for tracking. point.) An employer contact is counted even when an employment specialist meets the same employer 3= Employment specialist makes 4 face-to-face employer contacts more than one time in a week, and when the client per week that are client-specific, and uses a tracking form that is is present or not present. Client-specific and generic reviewed by the SE supervisor on a monthly basis. contacts are included. Employment specialists use a 153

159 weekly tracking form to document employer contacts. 4= Employment specialist makes 5 face-to-face employer contacts per week that are client-specific, and uses a tracking form that is reviewed by the SE supervisor on a weekly basis. 5= Employment specialist makes 6 or more face-to-face employer contacts per week that are client specific, or 2 employer contacts times the number of people looking for work when there are less than 3 people looking for work on their caseload (e.g., new program). In addition, employment specialist uses a tracking form that is reviewed by the SE supervisor on a weekly basis. 7. Job development - Quality of employer contact: DOC, INT, 1= Employment specialist meets employer when helping client to Employment specialists build relationships with OBS turn in job applications, OR Employment specialist rarely makes employers through multiple visits in person that are employer contacts. planned to learn the needs of the employer, convey what the SE program offers to the employer, describe 2= Employment specialist contacts employers to ask about job client strengths that are a good match for the employer. openings and then shares these leads with clients. (Rate for each employment specialist, then calculate average and use the closest scale point.) 3= Employment specialist follows up on advertised job openings by introducing self, describing program, and asking employer to interview client. 4= Employment specialist meets with employers in person whether or not there is a job opening, advocates for clients by describing strengths and asks employers to interview clients. 5= Employment specialist builds relationships with employers through multiple visits in person that are planned to learn the needs of the employer, convey what the SE program offers to the employer, describe client strengths that are a good match for the employer. 8. Diversity of job types: Employment specialists DOC, INT, 1= Employment specialists assist clients obtain different types of jobs assist clients in obtaining different types of jobs. OBS, ISP less than 50% of the time. 2= Employment specialists assist clients obtain different types of jobs 50-59% of the time. 3= Employment specialists assist clients obtain different types of jobs 60-69% of the time. 154

160 4= Employment specialists assist clients obtain different types of jobs70-84% of the time. 5= Employment specialists assist clients obtain different types of jobs % of the time. 9. Diversity of employers: Employment specialists DOC, INT, assist clients in obtaining jobs with different OBS, ISP 1= Employment specialists assist clients obtain jobs with the different employers. employers less than 50% of the time. 2= Employment specialists assist clients obtain jobs with the same employers 50-59% of the time. 3= Employment specialists assist clients obtain jobs with different employers 60-69% of the time. 4= Employment specialists assist clients obtain jobs with different employers 70-84% of the time. 5= Employment specialists assist clients obtain jobs with different employers % of the time. 10. Competitive jobs: Employment DOC, INT, 1= Employment specialists provide options for permanent, competitive specialists provide competitive job options OBS, ISP jobs less than 64% of the time, OR There are fewer than 10 current jobs. that have permanent status rather than temporary or time-limited status, e.g., TE (transitional 2= Employment specialists provide options for permanent, competitive jobs employment positions). Competitive jobs pay about 65-74% of the time. at least minimum wage, are jobs that anyone can apply for and are not set aside 3= Employment specialists provide options for permanent competitive jobs for people with disabilities. (Seasonal jobs about 75-84%% of the time. and jobs from temporary agencies that other community members use are counted as 4= Employment specialists provide options for permanent competitive jobs competitive jobs.) about 85-94% of the time. 5= 95% or more competitive jobs held by clients are permanent. 155

161 11. Individualized follow-along supports: DOC, INT, 1= Most clients do not receive supports after starting a job. Clients receive different types of support for OBS, ISP working a job that are based on the job, client 2= About half of the working clients receive a narrow range of supports preferences, work history, needs, etc. Supports are provided primarily by the employment specialist. provided by a variety of people, including treatment team members (e.g., medication changes, social 3= Most working clients receive a narrow range of supports that are provided skills training, encouragement), family, friends, co-workers primarily by the employment specialist. (i.e., natural supports), and employment specialist. Employment specialist also provides employer 4= Clients receive different types of support for working a job that are based support (e.g., educational information, job, on the job, client preferences, work history, needs, etc. Employment accommodations) at client s request. Employment specialists provide employer supports at the client s request. specialist offers help with career development, i.e., assistance with education, a more desirable job, 5= Clients receive different types of support for working a job that are based on the or more preferred job duties. job, client preferences, work history, needs, etc. Employment specialist also provides employer support (e.g., educational information, job accommodations) at client s request. The employment specialist helps people move onto more preferable jobs and also helps people with school or certified training programs. The site provides examples of different types of support including enhanced supports by treatment team members. 12. Time-unlimited follow-along supports: DOC, INT, 1= Employment specialist does not meet face-to-face with the client Employment specialists have face-to-face contact OBS, ISP after the first month of starting a job. within 1 week before starting a job, within 3 days after starting a job, weekly for the first month, and 2= Employment specialist has face-to-face contact with less than half of the at least monthly for a year or more, on average, working clients for at least 4 months after starting a job. after working steadily, and desired by clients. Clients are transitioned to step down job supports 3= Employment specialist has face-to-face contact with at least half of the from a mental health worker following steady employment. Employment specialists contact clients within 3 days of learning about the job loss. working clients for at least 4 months after starting a job. 4= Employment specialist has face-to-face contact with working clients weekly for the first month after starting a job, and at least monthly for a year or more, on average, after working steadily, and desired by clients. 5= Employment specialist has face-to-face contact within 1 week before starting a job, within 3 days after starting a job, weekly for the first month, and at least 156

162 monthly for a year or more, on average, after working steadily and desired by clients. Clients are transitioned to step down job supports, from a mental health worker following steady employment clients. Clients are transitioned to step down job supports from a mental health worker following steady employment. Employment specialist contacts clients within 3 days of hearing about the job loss. 13. Community-based services: Employment DOC, INT 1= Employment specialist spends 30% time or less in the scheduled services such as engagement, job finding OBS work hours in the community. and follow-along supports are provided in natural community settings by all employment 2= Employment specialist spends 30-39% time of total scheduled work hours specialists. (Rate each employment specialist based upon their total weekly scheduled work hours then, calculate the average and use the closest scale point.) in the community. 3= Employment specialist spends 40-49% of total scheduled work hours in the then community. 4= Employment specialist spends 50-64% of total scheduled work hours in the community. 5= Employment specialist spends 65% or more of total scheduled work hours in the community. 14. Assertive engagement and outreach by MIS, DOC, 1= Evidence that 2 or less strategies for engagement and outreach are used. integrated treatment team: Service termination INT, OBS is not based on missed appointments or fixed time 2= Evidence that 3 strategies for engagement and outreach are used. limits. Systematic documentation of outreach attempts. Engagement and outreach attempts made by integrated 3= Evidence that 4 strategies for engagement and outreach are used. team members. Multiple home/community visits. Coordinated visits by employment specialist with integrated 4= Evidence that 5 strategies for engagement and outreach are used. team member. Connect with family, when applicable. Once it is clear that the client no longer wants to work 5= Evidence that all 6 strategies for engagement and outreach are used: i) Service or continue SE services, the team stops outreach. termination is not based on missed appointments or fixed time limits. ii) Systematic documentation of outreach attempts. iii) Engagement and outreach attempts made by integrated team members. iv) Multiple home/community visits. v) Coordinated visits by employment specialist with integrated team member. vi) Connect with family, when applicable. 157

163 *Data sources: MIS Management Information System DOC Document review: clinical records, agency policy and procedures INT Interviews with clients, employment specialists, mental health staff, VR counselors, families, employers OBS Observation (e.g., team meeting, shadowing employment specialists) ISP Individualized Service Plan 2/14/96 6/20/01, Updated 1/7/08, Revised 158

164 Supported Employment Fidelity Scale Score Sheet Staffing 1. Caseload size Score: 2. Employment services staff Score: 3. Vocational generalists Score: Organization 1. Integration of rehabilitation with mental health thru team assignment Score: 2. Integration of rehabilitation with mental health thru frequent team member contact Score: 3. Collaboration between employment specialists and Vocational Rehabilitation counselors Score: 4. Vocational unit Score: 5. Role of employment supervisor Score: 6. Zero exclusion criteria Score: 7. Agency focus on competitive employment Score: 8. Executive team support for SE Score: Services = Exemplary Fidelity = Good Fidelity = Fair Fidelity 73 and below = Not Supported Employment 1. Work incentives planning Score: 2. Disclosure Score: 3. Ongoing, work-based vocational assessment Score: 4. Rapid search for competitive job Score: 5. Individualized job search Score: 6. Job development Frequent employer contact Score: 7. Job development Quality of employer contact Score: 8. Diversity of job types Score: 9. Diversity of employers Score: 10. Competitive jobs Score: 11. Individualized follow-along supports Score: 12. Time-unlimited follow-along supports Score: 13. Community-based services Score: 159

165 14. Assertive engagement and outreach by integrated treatment team Score: Total: 160

166 Attachment L: Co-occurring Disorders PowerPoint A Roadmap to Improve Services & Outcomes for Individuals with Co-Occurring Disorders Criminal Justice Coordinating Council and Behavioral Health Providers Dunn County, WI ~ March 22, 2012 Julienne Giard, MSW Consultant: Evidence-Based Practices and Co-Occurring Disorders Presentation Outline Evidence Based Practices Co-Occurring Disorders Treatment Protocol Data, Funding, Training, Resource Materials Case Vignette 161

167 This is the beginning of a long trip Evidence-Based Practices (EBPs) From a global perspective Overall, across the County system For individuals with/without COD Also includes Best Practices Database EBPs/BPs specific to co-occurring disorders (COD) 162

168 EBP/BPs Across all Services Gender-responsive services Person-centered recovery planning Recovery-oriented care Trauma-informed care EBPs at one or more locations ACT* CBT COS* DBT Diversion & Re-entry DDCAT EMDR Family Psychoeducation *Not in-jail IMR IDDT/DDCMHT MAT MI Psych Rehab Supported Employment* Supportive Housing* Trauma-specific 12-step facilitation 163

169 More on EBPs Some embedded in others MI, CBT, 12-step facilitation in DDCAT, DDCMHT and IDDT Point of implementation is different Individual-level (e.g., MAT, Psych Rehab) Team-based (e.g., ACT) Program-level models (e.g., DDCAT, IDDT) For different agency types Mental health, addiction treatment Subgroups of the Population with Co-Occurring Disorders Quadrant III High Severity SUD Low Severity MI Quadrant IV High Severity MI High Severity SUD Quadrant I Low Severity MI Low Severity SUD Quadrant II High Severity MI Low Severity SUD 164

170 Integrated Services Models and Program Assessment Measures -Integrated Dual Disorders Treatment (IDDT) model -Evidence-based model -Developed by Faculty at Dartmouth Medical School (Drs. Mueser, Drake, et al.) -Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index -More than 20 states currently using the DDCAT -Developed by Dr. McGovern at Dartmouth Medical School IDDT -14 items -Each rated on a 1-5 scale -Site visit methodology -CT developed algorithm to categorize results at MHOS, DDC, DDE 165

171 DDCAT -35 Items -7 Domains -Structure, Milieu, Assessment, Treatment, Continuity of Care, Staffing, Training -Each item rated on 1-5 scale -Site visit methodology -AOS, DDC, DDE -80% rule Site Visit Methodology -1/2 Day -Interview with program leadership -Interview with direct care staff -Client focus group -Chart reviews -Brief tour -Exit interview with program leadership -Written report 166

172 IDDT and DDCAT Summarized **All elements with a focus on co-occurring disorders -Program structure/milieu -Stage-Wise Interventions -Motivational Interviewing, CBT -Family Psychoeducation/Support -Pharmacological Treatment -12 Step Self-Help Groups -Continuity of Care -Staffing 167