The Virginia COSIG Project and the Virginia Service Integration Program
In late 2002, SAMHSA presented a landmark report to the U.S. Congress on the status and treatment of co-occurring disorders in the nation which outlined the need for a coordinated, integrated response to the problem. Congress subsequently appropriated funding to develop the State Infrastructure Grant Program for the Treatment of Persons with Co-Occurring Substance Related and Mental Health Disorders, also known as “COSIG”. The COSIG grant program is designed to provide funding to the States to develop or enhance their infrastructure and capacity to provide “accessible, effective, comprehensive, integrated and evidence-based treatment services” to persons with co-occurring substance abuse and mental disorders.
In Virginia, DBHDS and the CSBs have long recognized the need to integrate and improve services to this segment of our consumer population. Several years ago, this need gave rise to the Virginia Association of Community Services Boards’ (VACSB’s) “Co-Occurring Workgroup,” which was established to create a partnership and forum between the VACSB Mental Health and Substance Abuse councils for dialogue and action. Within this context, in October 2004 DBHDS applied for and was awarded a five-year, $3.5 million award under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) COSIG Program to enhance the screening, assessment and treatment of co-occurring mental illness and substance abuse (CODs) throughout Virginia’s public behavioral health system. Concurrent with the COSIG award, the Commonwealth was also selected to participate in SAMHSA’s second Policy Academy on CODs. Participation in the Policy Academy enabled state-level representatives from DBHDS, the Department of Medical Assistance Services (DMAS) and the VACSB to work with national-level experts to develop a State Action Plan for COD service integration.
Virginia’s COSIG Project began in May 2005 at a pilot group of 11 CSBs, and in 2006 was expanded to all CSBs and state mental health hospitals. The overall goal of the project is to enhance the state’s ability to identify and treat co-occurring mental health and substance use disorders through the following activities:
- Development of infrastructure statewide to support integration of mental health and substance abuse services through implementation of the Continuous, Comprehensive, Integrated System of Care for Co-Occurring Disorders, developed by Ken Minkoff, M.D. Three important elements of this model are the development of a State Charter Document which outlines the initial activities for DBHDS, in collaboration with the seven Partnership Planning Regions, the CSBs, Virginia’s state mental health hospitals, consumers and families, and other stakeholders to organize the first action steps for implementation of system change at each level of the system.
- Improved screening and assessment for CODs
- Workforce development and training, and
- Promotion of evidence- and consensus-based clinical practices.
In 2006, the name of this initiative was changed from the Virginia COSIG Project to the Virginia Services Integration Program (VASIP) to indicate that the integration of mental health and substance abuse treatment and other infrastructure development activities being promoted through the Virginia’s COSIG grant are not limited to the timeframe or funding of the federal grant – this process is part of our larger system transformation effort and will continue after the federal grant ends in September 2009.
Since its inception in early 2005, the VASIP/COSIG initiative has made a number of important accomplishments in furtherance of our goal of infrastructure development and service integration. These include the following:
Goal Area: Develop infrastructure to support service integration at all levels of the public system through implementation of Minkoff’s C ontinuous, Comprehensive, Integrated System of Care Model (CCISC).
Indicators (outcomes as of June 2007):
- Developed and disseminated a VASIP/COSIG State Charter Document to the CSBs and state mental health facilities outlining the initial activities for DBHDS, in collaboration with Regional Planning Partnerships, the CSBs, state hospitals, consumers and families, and other stakeholders to organize the first action steps for implementation of system change at each level of the system.
- VASIP Charter adopted/approved by 19 CSBs (47.5%) and two state facilities (25%).
- Empowered implementation teams developed to oversee CCISC/service integration at 19 CSBs (47.5%) and four state facilities (50%).
- Co-Morbidity Program Audit and Self-Survey (COMPASS) self-assessment tool completed at least once by 24 CSBs (60%) and two state facilities (25%); three additional CSBs and four facilities plan to complete the COMPASS in the near future.
- Quality improvement action plans developed from COMPASS results by 10 CSBs (25%) and one state facility (12.5%); seven additional CSBs plan to develop a QI plan in the near future.
- Technical assistance provided by Dr. Ken Minkoff, Dr. Chris Cline and/or project staff to CSBs in Partnership Planning Regions 1, 2, 4, 5, 6 and 7; Region 3 consultation planned for FY 2008. Drs. Minkoff and Cline also have provided consultation to a number of CSBs on an individual basis through local contracts.
- $826,000 in grant funds provided to CSBs and state facilities in FY 2007 to support infrastructure development through consultation and technical assistance.
- Funding for COD services expanded by working with DMAS to allow reimbursement for substance abuse treatment in the context of co-occurring disorders. This set the stage for the July 2007 Medicaid Substance Abuse reimbursement policy.
- FY 2008 Performance Contract modified to include long-term expectations for organizational self-assessment leading to dual diagnosis/co-occurring capability.
- COMPASS training video produced to assist CSBs and facilities in completing the COMPASS process. Video featured Dr. Cline providing a training on the COMPASS to New River Valley CSB staff in September 2005.
Goal Area: Develop capacity to provide treatment and other services to persons with CODs and promote the adoption of Evidence-Based Practices through workforce development and training activities.
- Over $310,000 in grant funds provided to CSBs in FY 2007 to support training in various clinical best practices. Through these trainings and Minkoff/Cline large-group sessions, project staff estimate that more than 3,000 clinicians from around the state have been trained with VASIP/COSIG grant funds.
- Minkoff/Cline large-group trainings provided on co-occurring disorders and the CCISC model to facility staff at Western State Hospital, Catawba Hospital and Southern Virginia Mental Health Institute. Training planned at Southwest Virginia Mental Health Institute in January 2008.
- Online VASIP Workforce Survey developed for implementation in FY 2008. Staff plan to survey CSB and state facility clinicians to get a snapshot of clinicians’ knowledge, skill and ability at treating MH/SA co-occurring disorders. UDPATE: The CSB version of the Workforce Survey went live on November 11, 2007. The state facility staff survey will be developed and implemented in early 2008.
- Produced training video “Co-Occurring Disorders and Substance Abuse: Information for Crisis Clinicians” for distribution to CSBs and state facilities. Video featured Carmen Greiner, Substance Abuse Manager at Crossroads CSB, providing this training to Region 1 and 2 ES workers in December 2006. Video has been distributed to all CSBs and state hospitals.
- Provided scholarships to the 2007 Virginia Summer Institute for Addiction Studies to 42 clinicians with a traditional mental health background, and also to five consumers with co-occurring disorders.
- Sponsored Round Table Discussion on Co-Occurring Disorders in Adolescents for CSB child and family services staff in FY 2006.
Goal Area: Develop State Steering Committee to provide stakeholder input into VASIP/COSIG activities.
- Consumers and advocates invited to join existing Steering Committee comprised of Department staff in July 2006.
- CSB and state facility representatives invited to join Steering Committee in December 2006. UPDATE: As of December 2007, the Committee includes representation from three state hospitals (Western State Hospital, Northern Virginia Mental Health Institute and Southern Virginia Mental Health Institute) and six of the seven regions.
- Committee voted to develop several subcommittees, including Membership, Welcoming, Training, and Architecture of Transformation (this last subcommittee was later disbanded).
- Training Subcommittee re-named itself the Professional Training and System Development (PTSD) Work Group and has developed a plan to address training needs identified by the Workforce Survey.
- Continue to support CCISC implementation through on-going technical assistance and training activities.
- Dr. Ken Minkoff to provide technical assistance to state facilities to improve co-occurring and recovery-oriented care to address issues identified by OIG report. Dr. Minkoff will also provide an introductory training on co-occurring disorders treatment to direct service staff in Regions 1 and 3 in January 2007.
- Implement Workforce Survey and analyze data.
- Present Workforce Survey data and training plan to senior leadership in the Department and the VACSB.
- Support development of Double Trouble in Recovery 12-step groups in the state hospitals (at a minimum).
- Pilot Ken Minkoff and Chris Cline’s “Change Agent” curriculum in Health Planning Region 2.