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Comprehensive, Continuous, Integrated Systems of Care for Co-Occurring Disorders

“Comprehensive, Continuous, Integrated Systems of Care” for Co-Occurring Disorders. To assist with the implementation of the Virginia COSIG project, DBHDS is consulting with two nationally-known experts in the field of COD treatment. Kenneth Minkoff, M.D., Clinical Assistant Professor of Psychiatry at Harvard Medical School, and Christie Cline, M.D., psychiatrist and president of Zialogic, Inc., have developed what they call the “Comprehensive, Continuous, Integrated System of Care” (CCISC) for Co-Occurring Disorders. The CCISC is designed to improve treatment capacity for these individuals in systems of any size and complexity, ranging from entire states, to regions or counties, networks of agencies, individual complex agencies, or even programs within agencies. The model has the following four basic characteristics:

1. System-Level Change: The CCISC model is designed for implementation throughout an entire system of care, not just for  implementation of individual program or training initiatives. The primary intent of the system change in this model is for  services to become Dual Diagnosis Capable or Dual Diagnosis Enhanced.  Dual Diagnosis Capable (DDC) programs routinely accept individuals who have co-occurring mental health and substance use disorders and can meet these consumers’ treatment needs, so long as their psychiatric disorders are sufficiently stabilized and do not interfere with participation in addiction treatment. Dual Diagnosis Enhanced (DDE) programs can accommodate individuals with CODs who may be unstable or disabled to such an extent that specific psychiatric and mental health supports, monitoring and accommodation are necessary in order for the individual to participate in addiction treatment. Such individuals are not so acute or impaired as to present a severe danger to themselves or others, nor do they require 24-hour, intensive psychiatric supervision.

Implementation of the CCISC model integrates the use of strategically planned system change technology such as Continuous Quality Improvement) with clinical practice technology at the system level, program level, clinical practice level, and clinician competency level to create comprehensive system change.

2. Efficient Use of Existing Resources: The CCISC model is designed for implementation within the context of current service resources, however scarce, and emphasizes strategies to improve services to persons with CODs within the context of available funding, contracting policies and data collection needs. It provides a template for planning how to obtain and utilize additional resources should they become available, but does not require additional resources, other than resources for planning, technical assistance, and training. The most basic implementation strategy involves exploring regulatory guidelines for any funding source (Medicaid, for example) in any program or service (mental health center, primary care clinic, etc.) and providing a specific set of guidelines and instructions for how to provide and document integrated treatment within the context of existing funding.

3. Incorporation of Best Practices: The CCISC model is recognized by SAMHSA as a best practice for systems implementation for treatment of persons with CODs. An important aspect of CCISC implementation is the incorporation of Evidence-Based and clinical consensus-based best practices for the treatment of all types of CODs throughout the service system. This is based on the recognition that CODs are not a single entity with a single “best practice” intervention, but rather that individuals with CODs have a wide range of disorders and needs, and that the most successful way to treat their multiple needs is by integrating the best treatment for each disorder at the level of the client. This encourages the system to develop as extensive a range of best practices for mental health and substance disorders as it can, and organize them so that any best practice for either type of disorder is provided in a Dual Diagnosis Capable fashion.

4. Integrated Treatment Philosophy: The CCISC model is based on implementation of principles of successful treatment intervention that are derived from available research and incorporated into an integrated treatment philosophy that utilizes a common language that makes sense from the perspective of both mental health and substance disorder providers. This model can be used to develop a protocol for the design of individualized treatment that supports matching individual client needs with the most appropriate best-practice treatment available.

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The Eight Principles of Treatment for the CCISC

The eight research-derived and consensus-derived principles that guide the implementation of the CCISC are as follows:

1. Dual diagnosis is an expectation, not an exception: Epidemiologic data defining the high prevalence of co-morbidity, along with clinical outcome data associating individuals with CODs with poor outcomes and high costs in multiple systems, imply that the whole system, at every level, must be designed to use all of its resources in accordance with this expectation. This implies the need for an integrated system planning process, in which each funding stream, each program, all clinical practices, and all clinician competencies are designed proactively to address the individuals with co-occurring disorders who present in each component of the system already.

2. All individuals with CODs are not the same; the national consensus four quadrant model for categorizing co-occurring disorders can be used as a guide for service planning on the system level. In this model, INDIVIDUALS WITH CODS can be divided according to high and low severity for each disorder, into high-high (Quadrant IV), low MH – high CD (Quadrant III), high MH – low CD (Quadrant II), and low-low (Quadrant I). High MH individuals usually have SPMI and require continuing integrated care in the MH system. High CD individuals are appropriate for receiving episodes of addiction treatment in the CD system, with varying degrees of integration of mental health capability.

3. Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting; provision of continuous integrated treatment relationships is an evidence based best practice for individuals with the most severe combinations of psychiatric and substance difficulties. The system needs to prioritize (a) the development of clear guidelines for how clinicians in any service setting can provide integrated treatment in the context of an appropriate scope of practice, and (b) access to continuous integrated treatment of appropriate intensity and capability for individuals with the most complex difficulties.

4. Case management and care must be balanced with empathic detachment, expectation, contracting, consequences, and contingent learning for each client, and in each service setting. Each individual client may require a different balance (based on level of functioning, available supports, external contingencies, etc.); and in a comprehensive service system different programs are designed to provide this balance in different ways. For example, dual diagnosis housing for individuals with SPMI may incorporate programming that is dry, damp, and wet. On an individual client level, individuals who require high degrees of support or supervision can utilize contingency based learning strategies involving a variety of community-based reinforcers to make incremental progress within the context of continuing treatment.

5. When psychiatric and substance disorders coexist, both disorders should be considered primary, and integrated dual (or multiple) primary diagnosis-specific treatment is recommended. The system needs to develop a variety of administrative, financial, and clinical structures to reinforce this clinical principle, and to develop specific practice guidelines emphasizing how to integrate diagnosis-specific best practice treatments for multiple disorders for clinically appropriate clients within each service setting. This incorporates psychopharmacology guidelines that define the expectation of continuing necessary non-addictive medication for the treatment of known serious mental illness for individuals who are continuing to use substances. This incorporates the utilization of specific “disease management” skills training in either disorder to individuals in treatment for the other disorder, including adaptation of skills training in substance abuse reduction or elimination skills to individuals who have psychiatric disabilities.

6. Both mental illness and addiction can be treated within the philosophical framework of a “disease and recovery model” with parallel phases of recovery (acute stabilization, motivational enhancement, active treatment, relapse prevention, and rehabilitation/recovery), in which interventions are not only diagnosis-specific, but also specific to phase of recovery and stage of change. Literature in both the addiction field and the mental health field has emphasized the concept of stages of change or stages of treatment, and demonstrated the value of stage-wise treatment.

7. There is no single correct intervention for individuals with CODs ; for each individual interventions must be individualized according to quadrant, diagnoses, level of functioning, external constraints or supports, phase of recovery/stage of change, and (in a managed care system) multidimensional assessment of level of care requirements. This principle forms the basis for developing clinical practice guidelines for assessment and treatment matching. It also forms the basis for designing the template of the CCISC, in which each program is a dual diagnosis program, but all programs are not the same. Each program in the system is assigned a “job”: to work with a particular cohort of ICOPSD, providing continuity or episode interventions, at a particular level of care. Consequently, all programs become mobilized to develop cohort specific dual diagnosis services, thereby mobilizing treatment resources throughout the entire system.

8. Clinical outcomes for individuals with CODs must also be individualized, based on similar parameters for individualizing treatment interventions. Abstinence and full mental illness recovery are usually long term goals, but short term clinical outcomes must be individualized, and may include reduction in symptoms or use of substances, increases in level of functioning, increases in disease management skills, movement through stages of change, reduction in “harm” (internal or external), reduction in service utilization, or movement to a lower level of care. Systems need to develop clinical practice parameters for treatment planning and outcome tracking that legitimize this variety of outcome measures to reinforce incremental treatment progress and promote the experience of treatment success.

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The implementation of a complex, multi-layered system model requires an organized approach, incorporating principles of strategic planning and continuous quality improvement in an incremental process that involves interaction between all layers of the system (system, agency or program, clinical practice and policy, clinician competency and training) and all components of the system, regardless of the size or complexity of the system. Implementation can occur in systems of any size (entire state, regions, counties, complex agencies, individual programs), and in any population or funding stream (adults, elders, children; Medicaid, private payers, state block grant funds; urban/rural; culturally diverse populations). In order organize the complexity of this process the authors have developed the “Twelve Step Program of Implementation” (first implemented in Michigan in 2002), and have created a CCISC Toolkit to provide a framework for evaluating and monitoring progress at the system level, the program level, and the clinician level.

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Twelve Steps for CCISC Implementation

1. Integrated system planning process: Implementation of the CCISC requires a system-wide integrated strategic planning process that can address the need to create change at every level of the system, ranging from system philosophy, regulations, and funding, to program standards and design, to clinical practice and treatment interventions, to clinician competencies and training. The integrated system planning process must be empowered within the structure of the system, include all key funders, providers, and consumer/family stakeholders, have the authority to oversee continuing implementation of the other elements of the CCISC, utilize a structured process of system change (e.g., continuous quality improvement), and define measurable system outcomes for the CCISC in accordance with the elements listed herein. It is necessary to include consumer and family driven outcomes that measure satisfaction with the ability of the system to be welcoming, accessible and culturally competent, as well as integrated, continuous, and comprehensive, from the perspective of ICOPSD and their families. The CCISC Outcome Fidelity and Implementation Tool (COFIT-100™) has been developed by the authors to facilitate this outcome measurement process at the system level.

2. Formal consensus on CCISC model: The system must develop a clear mechanism for articulating the CCISC model, including the principles of treatment and the goals of implementation, developing a formal process for obtaining consensus from all stakeholders, identifying barriers to implementation and an implementation plan, and disseminating this consensus to all providers and consumers within the system.

3. Formal consensus on funding the CCISC model: CCISC implementation involves a formal commitment that each funder will promote integrated treatment within the full range of services provided through its own funding stream, whether by contract or by billable service CODe, in accordance with the principles described in the model, and in accordance with the specific tools and standards described below. Blending or braiding funding streams to create innovative programs or interventions may also occur as a consequence of integrated systems planning, but this alone does not constitute fidelity to the model.

4. Identification of priority populations, and locus of responsibility for each: Using the national consensus four quadrant model, the system must develop a written plan for identifying priority populations within each quadrant, and locus of responsibility within the service system for welcoming access, assessment, stabilization, and integrated continuing care. Commonly, individuals in quadrant I are seen in outpatient and primary care settings, individuals in quadrant II and some in quadrant IV are followed within the mental health service system, individuals in quadrant III are engaged in both systems but served primarily in the substance system. Each system will usually have priority populations (commonly in quadrant IV) with no system or provider clearly responsible for engagement and/or treatment; the integrated system planning process needs to create a plan for how to address the needs of these populations, even though that plan may not be able to be immediately implemented.

5. Development and implementation of program standards: A crucial element of the CCISC model is the expectation that all programs in the service system must meet basic standards for Dual Diagnosis Capability, whether in the mental health system (DDC-MH) or the addiction system (DDC-CD). In addition, within each system of care, for each program category or level of care, there need to written standards for Dual Diagnosis Enhanced programs (DDE). There needs to be consensus that these standards will be developed, and that, over time, they will be built into funding and licensing expectations (see items 2 and 3 above), as well as a plan for stage-wise implementation. Program competency assessment tools (e.g., the Co-Morbidity Program Audit and Self-Survey [COMPASS™]) can be helpful in both development and implementation of DDC standards.

6. Structures for intersystem and inter-program care coordination: CCISC implementation involves creating routine structures and mechanisms for addiction programs and providers and mental health programs and providers, as well as representatives from other systems that may participate in this initiative (e.g., corrections) to participate in shared clinical planning for complex cases whose needs cross traditional system boundaries. Ideally, these meetings should have both administrative and clinical leadership, and should be designed not just to solve particular clinical problems, but also to foster a larger sense of shared clinical responsibility throughout the service system. A corollary of this process may include the development of specific policies and procedures formally defining the mechanisms by which mental health and addiction providers support one another and participate in collaborative treatment planning.

7. Development and implementation of practice guidelines: CCISC implementation requires system wide transformation of clinical practice in accordance with the principles of the model. This can be realized through dissemination and incremental developmental implementation via CQI processes of clinical consensus best practice service planning guidelines that address assessment, treatment intervention, rehabilitation, program matching, psychopharmacology, and outcome. Obtaining input from, and building consensus with clinicians prior to final dissemination is highly recommended.

Existing documents are available to facilitate this process. Practice guideline implementation must be supported by regulatory changes (both to promote adherence to the guidelines and to eliminate regulatory barriers) and by clinical auditing and self-monitoring procedures to monitor compliance. Specific guidelines to facilitate access and identification and to promote integrated continuous treatment are a particular priority for implementation, (See items 8 and 9).

8. Facilitation of identification, welcoming, and accessibility: This requires several specific steps:  (a) Modification of MIS capability to facilitate and incentivize accurate identification, reporting, and tracking of ICOPSD;  (b) Development of “no wrong door” policies and procedures that mandate a welcoming approach to ICOPSD in all system programs, eliminate arbitrary barriers to initial evaluation and engagement, and specify mechanisms for helping each client (regardless of presentation and motivation) to get connected to a suitable program as quickly as possible; and  
(c) Establishing policies and procedures for universal screening for co-occurring disorders at initial contact throughout the system.

9. Implementation of continuous integrated treatment: Integrated treatment relationships are a vital component of the CCISC. Implementation requires developing the expectation that primary clinicians in every treatment setting are responsible for developing and implementing an integrated treatment plan in which the client is assisted to follow diagnosis specific and stage specific recommendations for each disorder simultaneously. This expectation must be supported by clear definition of the expected “scope of practice” for singly licensed clinicians regarding co-occurring disorder, and incorporated into standards of practice for reimbursable clinical interventions – in both mental health and substance settings – for individuals who have co-occurring disorders.

10. Development of basic dual diagnosis capable competencies for all clinicians: Creating the expectation of universal competency, including attitudes and values, as well as knowledge and skill, is a significant characteristic of the CCISC model. Available competency lists for co-occurring disorders can be used as a reference for beginning a process of consensus building regarding the competencies. Mechanisms must be developed to establish the competencies in existing human resource policies and job descriptions, to incorporate them into personnel evaluation, credentialing, and licensure, and to measure or monitor clinician attainment of competency. Competency assessment tools (e.g., the Co-Occurring Disorders Educational Competency Assessment Tool [CODECAT™]) can be utilized to facilitate this process.

11. Implementation of a system wide training plan: In the CCISC model, training must be ongoing, and tied to expectable competencies in the context of actual job performance. This requires an organized training plan to bring training and supervision to clinicians on site. The most common components of such training plans involve curriculum development and dissemination, mechanism for training and deploying trainers, career ladders for advanced certification, and opportunities for experiential learning. Train-the-trainer curricula have been developed that have been adapted for use in a variety of state and regional systems, and which emphasize that the trainers are actually positioned individually and collectively as “system change agents” to link system managers with front line clinicians in order to appropriately advocate for policy to support good clinical practice, and to transmit that policy in turn to direct care staff.

12. Development of a plan for a comprehensive program array: The CCISC model requires development of a strategic
plan in which each existing program begins to define and implement a specific role or area of competency with regard
to provision of Dual Diagnosis Capable or Dual Diagnosis Enhanced service for people with co-occurring disorders,
primarily within the context of available resources. This plan should also identify system gaps that require longer
range planning and/or additional resources to address, and identify strategies for filling those gaps. Four important
areas that must be addressed in each CCISC are:

(a) Evidence-based best practice: There needs to be a specific plan for identification of any evidence-based best practice for any mental illness (e.g. Individualized Placement and Support for vocational rehabilitation) or substance disorder (e.g. buprenorphine maintenance), or an evidence based best practice program model for a particular co-occurring disorder population (e.g. Integrated Dual Disorder Treatment for SPMI adults in continuing mental health care) that may be needed but not yet be present in the system, and planning for the most efficient methods to promote implementation in such a way that facilitates access to co-occurring clients that might be appropriately matched to that intervention.

(b) Peer dual recovery supports: The system can identify at least one dual recovery self-help program (e.g., Dual Recovery Anonymous [39], Double Trouble in Recovery [40]) and establish a plan to facilitate the creation of these groups throughout the system. The system can also facilitate the development of other peer supports, such as peer outreach and peer counseling.

(c) Residential supports and services: The system should begin to plan for a comprehensive range of programs that addresses a variety of residential needs, building initially upon the availability of existing resources through redesigning those services to be more explicitly focused on ICOPSD. This range of programs should include:

1. DDC/DDE addiction residential treatment (e.g., modified therapeutic community programs)

2. Abstinence-mandated (dry) supported housing for individuals with psychiatric disabilities.

3. Abstinence-encouraged (damp) supported housing for individuals with psychiatric disabilities

4. Consumer-choice (wet) supported housing for individuals with psychiatric disabilities at risk of homelessness.

5. Continuum of levels of care: All categories of service for ICOPSD should be available in a range of levels of care, including outpatient services of various levels of intensity; intensive outpatient or day treatment, residential treatment, and hospitalization. This can often be operationalized in managed care payment arrangements and may involve more sophisticated level of care assessment capacity.

CCISC implementation is an ongoing quality improvement process that encourages the development of a plan that includes attention to each of these areas in a comprehensive service array.

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