Checklist: Dual Diagnosis Capability Agency / Service Level A tool for any Mental Health or Substance Treatment service to self-assess, reflect on and plan around their service s level of dual diagnosis capability Eastern Hume Dual Diagnosis Group Supported by the Victorian Dual Diagnosis Initiative Eastern Hume Dual Diagnosis Service Northeast Health Wangaratta Integrated Primary Mental Health Service Version 6.0 / 2009 / Gary Croton, Northeast Health Wangaratta.
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About this checklist: This tool uses the term dual diagnosis to refer to co-occurring mental health and substance use disorders. Depending on the readers preference the terms comorbidity, co-existing disorders, concurrent disorders and co-occurring disorders may be substituted for dual diagnosis. If any potential user would like a version in which their preferred term has been substituted for dual diagnosis please contact the author with your request. This checklist was developed as a tool for Clinical Mental Health, Alcohol and Other Drug and Psychiatric Disability Support services, in any service system, to self-assess, reflect on and plan around their service s level of dual diagnosis capability The checklist may be used as a dual diagnosis training needs analysis tool The checklist may be used to develop an Action Plan (including any training needs) and assign responsibilities towards further developing a service s dual diagnosis capability. Companion checklists include: o Dual Diagnosis Capability: AT&OD and Mental Health Services Victorian version (aligned with the Victorian dual diagnosis policy) o Dual Diagnosis Capability: Alcohol, Tobacco and Other Drug Worker o Dual Diagnosis Capability: Clinical Mental Health Worker o Dual Diagnosis Capability: General Practitioner o Dual Diagnosis Capability: Primary Care Worker o Dual Diagnosis Capability: Psychiatric Disability Rehabilitation and Support Service Worker Completion of this checklist is a Quality Improvement activity and may be cited as evidence of the service s evolving dual diagnosis capability. Completing the checklist at 6-monthly intervals will allow services to measure and record their progress in developing dual diagnosis capability. The Dual Diagnosis Capability: AOD and Mental Health Services (Non- Victorian version) and the Dual Diagnosis Capability: AOD and Mental Health Services (Victorian version) Checklists use virtually identical criteria. The non-victorian version is structured around 5 domains -() Agency policy and documentation (2) Detection and Assessment of co-occurring Mental Health and Substance Use Disorders (3) Integrated Treatment of co-occurring Mental Health and Substance Use Disorders (4) Working with the broader service system (5) Agency Quality Assurance. The Victorian version is structured around the five Service Development Outcomes (SDOs) in the Victorian dual diagnosis policy Dual Diagnosis: Key directions and priorities for service development (State of Victoria, March 2007). 3
Using this checklist: This tool is best used as an agency-level, internal, all staff inclusive, strength s-focused, review of agency progress towards developing agency dual diagnosis capability. The team discussions, group reflection, information sharing and learnings around agency progress towards dual diagnosis capability constitute the principle benefit of using this tool. Hence it is important to involve as many members of the team as possible in completing this checklist. At a minimum, if it is logistically impossible to involve all staff members, representatives of all levels of staff, from new members to senior management and consumer and carer representatives should be involved. It is important that team members understand that there is no wrong answer that the development of agency dual diagnosis capability is most usefully regarded as an evolutionary development process which can be augmented by team self-reflection and planning. The tool has been designed to recognise existing agency achievements in developing dual diagnosis capability while developing a plan to further evolve agency dual diagnosis capability. Suggested 6-monthly intervals between completing agency reviews and further developing a service s Dual Diagnosis Capability Action Plan 4
Abbreviations: AT&OD CMH MH PDRSS PTSD SDO SMI S&AP SUDs Alcohol Tobacco & Other Drug Service Clinical Mental Health Service Mental Health applicable Psychiatric Disability Rehabilitation & Support Service Post Traumatic Stress Disorder Service Development Outcome Severe Mental Illness Screening and Assessment Protocol Substance Use Disorders 5
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Domain One: Agency policy and documentation. Service descriptions and mission statements reflect the service s commitment to, as core business for the service, identifying clients with, and providing integrated treatment for, co-occurring mental health and substance use disorders Integrated treatment is defined as: EITHER one worker or team provides treatment of both disorders OR staff of separate agencies work together to agree and implement a Individual Treatment Plan with ongoing formal interaction and co-operation in reassessing and treating the client 0.2 The service has local policy that states explicitly that the presence of a co-occurring mental health or substance use disorder is never used to exclude persons from receiving services 0 7
.3 All position descriptions reflect the expectation that all staff are dual diagnosis capable (or be working towards same) At a minimum, basic dual diagnosis capability means being confident and capable in: Screening for dual diagnosis Conducting a more detailed assessment that enables the development of an integrated treatment and care plan Being aware of and able to use agreed referral pathways within and between services Being able to consult others with more advanced knowledge and skills in making decisions about the most appropriate course of action 0.4 Position descriptions, for all positions above base-grade positions, include criteria around advanced dual diagnosis capability (either or working towards same) Advanced dual diagnosis capability refers to the ability to demonstrate knowledge and skills in planning and delivery of integrated treatment and care and the provision of supervision and support to other staff providing treatment and care to persons with dual diagnosis 0 8
.5 Service has developed a Screening and Assessment Protocol that details the service s preferred approaches to detecting and assessing cooccurring substance use and mental health disorders Screening and Assessment Protocol includes: Who should be screened /When /Preferred screening tools and their cut-off scores Responses to positive screens (usually conducting an assessment to confirm whether a co-occurring mental health or substance use disorder is indeed present and to provide adequate information to inform integrated treatment planning around both disorders) Procedures for recording results Possible treatment pathways in response to positive assessments 0 DOMAIN ONE Multiply by Total Domain One Score 00 Maximum Possible Score (N.B. reduce maximum possible score by 0 for each criteria deemed ) 50 Domain One Percentage Score % 9
Domain Two: Detection and Assessment of co-occurring Mental Health and Substance Use Disorders Screening is only a component of an assessment. Screening is best regarded as a brief method of determining whether a particular disorder (e.g. substance use or mental health disorder) may or may not be present. Generally positive screens will need to be followed up with a detailed assessment to confirm whether the disorder is indeed present and to provide sufficient information to allow effective treatment planning N.B. If a service has the capacity, time and expertise to incorporate routine assessment of co-occurring disorders into their intake assessment processes, then screening is superfluous and items 2. 2.5 will be 2. Routine service entry documentation includes a screen to detect the presence of possible co-occurring substance use or mental health disorders N.B. If a service has the capacity, time and expertise to incorporate routine assessment of co-occurring disorders into their routine intake assessment processes, then screening is superfluous and this criteria will be 0 2.2 Screening tool/s chosen by the agency have adequate sensitivity and specificity to detect the most prevalent co-occurring disorders in the services target population For AOD services do the screens detect a range of possible mental health disorders? For MH services do the screens detect both Substance Abuse and Substance Dependence? Are the screen/s able to detect the range of possible substance use disorders? 0 0
2.3 Percentage of persons assessed for entry to the service who are routinely screened for a co-occurring disorder (as close as possible in time to initial assessment) < 0% c. 20% 2 c. 30% 3 c. 40% 4 c. 50% 5 c. 60% 6 c. 70% 7 c. 80% 8 c. 90% 9 c. 00% 0 2.4 All clinicians and workers have had training around the service s methods of (and rationale for) routine screening for co-occurring mental health or substance use disorders 0
2.5 All clinicians and workers are confident and competent in using the service s screen/s to detect possible co-occurring substance use or mental health disorders 0 2.6 Staff orientation manuals and procedures facilitate new staff adopting the service s preferred approach to screening for and assessment of co-occurring substance use or mental health disorders 0 2
2.7 Service entry documentation includes comprehensive assessment criteria for co-occurring substance use or mental health disorders (i.e. assessment tools for use when screening is positive). For MH services a full AOD assessment proforma For AOD services a full Mental State Assessment proforma 0 2.8 Assessment documentation assists clinicians to record all relevant diagnoses To facilitate treatment planning around all presenting disorders 0 3
2.9 Assessment proformas facilitate the identification of the client s Stage of Change to both disorders 0 2.0 Percentage of service s clinicians and workers who have received training in conducting an assessment of co-occurring substance use or mental health disorders < 0% c. 20% 2 c. 30% 3 c. 40% 4 c. 50% 5 c. 60% 6 c. 70% 7 c. 80% 8 c. 90% 9 c. 00% 0 4
2. Percentage of service s clinicians and workers who are confident and competent in conducting an assessment of co-occurring substance use or mental health disorders For MH services a full AOD assessment For AOD services a full Mental State Assessment < 0% c. 20% 2 c. 30% 3 c. 40% 4 c. 50% 5 c. 60% 6 c. 70% 7 c. 80% 8 c. 90% 9 c. 00% 0 2.2 Where it is outside staff capacity to conduct a comprehensive assessment of any detected co-occurring disorder formal arrangements exist with local specialist services to provide either Secondary Consultation or the required assessment 0 DOMAIN TWO Multiply by Total Domain Two Score 00 Maximum Possible Score (N.B. reduce maximum possible score by 0 for each criteria deemed ) 20 Domain Two Percentage Score % 5
Domain Three: Integrated Treatment of co-occurring Mental Health and Substance Use Disorders 3. Percentage of service s workers and clinicians who have a well-developed understanding of integrated treatment and the possible pathways to achieve integrated treatment Integrated treatment is defined as: EITHER one worker or team provides treatment of both disorders OR staff of separate agencies work together to agree and implement a Individual Treatment Plan with ongoing formal interaction and co-operation in reassessing and treating the client < 0% c. 20% 2 c. 30% 3 c. 40% 4 c. 50% 5 c. 60% 6 c. 70% 7 c. 80% 8 c. 90% 9 c. 00% 0 3.2 Percentage of service s workers and clinicians who have well developed skills in providing treatment of or support for co-occurring mental health or substance use disorders For MH clinicians and workers this includes skills in the provision of Brief Interventions, Motivational Interviewing, Relapse Prevention, Psychopharmacology for persons with co-occurring SUDS, managing and facilitating treatment of withdrawal For AOD workers this includes skills in managing and facilitating treatment of symptoms of Anxiety, Depression, PTSD, Personality Disorder < 0% c. 20% 2 c. 30% 3 c. 40% 4 c. 50% 5 c. 60% 6 c. 70% 7 c. 80% 8 c. 90% 9 c. 00% 0 6
3.3 Co-occurring substance use or mental health diagnoses are recorded (with equal prominence) in the client s notes 0 DOMAIN THREE Multiply by Total Domain Three Score 00 Maximum Possible Score (N.B. reduce maximum possible score by 0 for each criteria deemed ) 30 Domain Three Percentage Score % 7
Domain Four: Working with the broader service system 4. All staff are confident and competent in engaging local specialist services in providing Secondary Consultation or Assessment 0 4.2 Service s individual treatment and care plan proformas facilitate multi-agency formal interaction and co-operation in reassessing and treating the client 0 8
4.3 Staff orientation procedures include a brief placement in the other service sector 0 4.4 Formal agreements are in place with other local specialist AT&OD or MH services that define client care pathways between the services Agreements include guidelines and agreed procedures around referral mechanisms, information sharing, client consent, case conferencing, secondary consultation and the provision of service in the other agency s premises 0 9
4.5 Above agreements and their utility in more effectively meeting client needs are the basis of ongoing monitoring and collaborative review by the partner agencies 0 4.6 Formal agreements are in place with other local specialist AT&OD or MH services around which service and sector has primary treatment responsibility for the different cohorts of persons with dual diagnosis e.g. Three level schema for responding to dual diagnosis p 4 of Dual Diagnosis: Key directions and priorities for service development / USA four quadrant model 0 20
4.7 Above formal agreements were developed from a series of consultations between local AT&OD and MH services that: - served to develop trust and communication between the services and their workers - built workers understanding of the mission, operation of and service constraints experienced by partner agencies - contributed to the development of a common language - defined each service s roles and responsibilities in the partnership - developed agreements tailored to local conditions and needs 0 4.8 Strategies are in place to promote ongoing, formal and informal, contacts between workers from local AT&OD and MH services e.g. Staff rotations; routine staff placements of staff during their service orientation; routine reciprocal education and training, service provision from the opposite service s premises 0 2
4.9 Formal agreements between local services include agreed mechanisms and approaches to dispute resolution around multi-agency service provision 0 4.0 There is evidence that each partner service routinely collaborates on the development of Individual Service Plans 0 22
4. The service has an (agreed with partner services) Integrated Treatment Plan proforma for those occasions when integrated treatment is provided by multiple, agencies working closely together Integrated treatment is defined as: EITHER one worker or team provides treatment of both disorders OR staff of separate agencies work together to agree and implement a Individual Treatment Plan with ongoing formal interaction and co-operation in reassessing and treating the client 0 4.2 There is evidence that this service routinely delivers assessment and treatment from the premises of the partner agency/s 0 23
4.3 There is evidence that partner agency/s routinely deliver assessment and treatment from this service s premises 0 4.4 The service has developed an agency Secondary Consultation policy that supports clinicians and workers in providing effective Secondary Consultation 0 24
4.5 Clinicians and workers have received training around the skills necessary to seek and to provide effective Secondary Consultation 0 4.6 Staff orientation manuals and procedures support new workers in developing the skills and attitudes necessary to seek and to provide effective Secondary Consultation 0 25
4.7 No Wrong Door values are written into all service and agency descriptions A No Wrong Door policy ensures that individuals needing treatment are identified and assessed and receive treatment, either directly or through appropriate referral, no matter where they enter the service system. That when clients appear at a facility not qualified to provide the service that they need, those clients are welcomed and guided to appropriate, cooperating facilities, with follow-up to ensure that they have received proper care. 0 4.8 Clinicians and workers receive ongoing training around the concept of, and their contribution to the development of, a No Wrong Door service system 0 26
4.9 The service routinely, with partner specialist agencies, monitors, evaluates and plans around: - frequency of diagnosis of co-occurring disorders - identification of cohorts or persons with co-occurring disorders - provision of multi-agency integrated treatment of co-occurring disorders - outcomes for persons with co-occurring disorders receiving multi-agency integrated treatment 0 DOMAIN FOUR Multiply by Total Domain Four Score 00 Maximum Possible Score (N.B. reduce maximum possible score by 0 for each criteria deemed ) 90 Domain Four Percentage Score % 27
Domain Five: Agency Quality Assurance 5. The service routinely, internally, monitors, evaluates and plans around: - frequency of screening - frequency of assessment of co-occurring disorders - frequency of provision of integrated treatment of co-occurring disorders - outcomes for persons with co-occurring disorders relative to outcomes for persons without co-occurring disorders 0 5.2 File audit, quality-control, processes include criteria to audit the frequency of screening for and assessment of co-occurring disorders 0 28
5.3 File audit, quality-control, processes include criteria to audit the frequency of the delivery of integrated treatment to persons presenting with dual diagnosis Integrated treatment is defined as: EITHER one worker or team provides treatment of both disorders OR staff of separate agencies work together to agree and implement a Individual Treatment Plan with ongoing formal interaction and co-operation in reassessing and treating the client 0 5.4 The service provides (or promotes staff participation in) ongoing, recurrent education and training around screening for, assessment of and integrated treatment for co-occurring mental health and substance use disorders 0 29
5.5 Education and training delivery is supported by access to dual diagnosis capable oriented Clinical Supervision 0 5.6 Staff orientation procedures include training in the service s approach to integrated screening, assessment and treatment 0 30
5.7 Individual staff appraisal procedures include discussion of, and planning around, clinician s and worker s progress in developing dual diagnosis capability 0 5.8 The service has an identified dual diagnosis portfolio holder, with relevant experience and training, whose role includes building the service s capacity to better recognise and respond more effectively to the needs of persons with co-occurring disorders 0 3
5.9 The service s dual diagnosis portfolio holder has the seniority and standing within the team to be able to influence the practice of coworkers and overall service delivery 0 5.0 The dual diagnosis portfolio holder remuneration, seniority and workload allocation reflect the service s recognition of the complexity and demands of building the service s capacity to respond more effectively to the needs of persons with co-occurring disorders 0 32
5. In services in which no worker has the relevant experience and training to fill this role priority is given to (and resources devoted to) developing the relevant experience and training in interested staff members e.g. funding advanced studies, participating in a Rotation in the other sector, receiving Clinical Supervision from specialist dual diagnosis workers 0 5.2 Positive screens and assessments (of co-occurring MH or AT&OD disorders) are recorded in the service s client database. 0 33
5.3 The service s client database is used to record when positive screens are followed up with - assessment - in-house integrated treatment - multi-agency integrated treatment utilizing a common Individual Treatment Plan 0 5.4 Outcome measures include measures that monitor outcomes of the treatment provided for any co-occurring mental health or substance use disorder 0 34
5.5 The service s client database is modified to enable comparisons between outcomes for persons with and without co-occurring mental health and substance use disorders. 0 5.6 Experience and expertise in dual diagnosis is a criterion for the appointment of Consumers and Carer consultant positions. 0 35
5.7 Consumers and Carers are centrally involved in the planning and evaluation of service responses for clients with dual diagnosis. 0 5.8 Consumers and Carers routinely critically evaluate education and training packages around dual diagnosis. 0 36
5.9 Consumers and Carers have a role in the delivery of education and training packages around dual diagnosis. 0 DOMAIN FIVE Multiply by Total Domain Five Score 00 Maximum Possible Score (N.B. reduce maximum possible score by 0 for each criteria deemed ) 90 Domain Five Percentage Score % Dual diagnosis capability Action Plan 37
AOD or Mental Health Agency Agency: Sector: ----- Date of agency self assessment: / / Our dual diagnosis capability domain scores: Policy & Documentation One: Detection & Assessment Two: Integrated Treatment Three: Broader Service System Four: Quality Assurance Five: % % % % % Summary: Agency dual diagnosis training needs:. Domain One: Policy & Documentation 2. Domain Two: Detection & Assessment 3. Domain Three: Integrated Treatment 4. Domain Four: Broader Service System 5. Domain Five: Quality Assurance Summary: Actions to further develop our agency s dual diagnosis capability. Domain One: Policy & Documentation By: Timelines 38
2. Domain Two: Detection & Assessment 3. Domain Three: Integrated Treatment By: By: 4. Domain Four: Broader Service System 5. Domain Five: Quality Assurance By: By: Date of our next self assessment: / / Version 6.0 / 2009 / Gary Croton, Northeast Health Wangaratta. 39