1

Center for Excellence in Integrated Care (CEIC)

Getting to Capable: Status of New York's OMH and

OASAS Outpatient Services in Providing Integrated Care

Stanley Sacks, PHD, CIRP, NDRI, New York, NYMichael Chaple, PHD, CIRP, NDRI, New York, NYChackuMathai, CPRP, NYAPRS, Albany, NY

presentation to — NYAPRS 29th Annual Conference, “Bringing Recovery Home for All,”September 14-16, 2011, Hudson Valley Resort and Conference Center, Kerhonkson, NY

2

What is CEIC’s purpose?

Fosters the implementation

of integrated care in screening, assessment, and evidence-based interventions

for New York State (NYS) residents with co-occurring conditions

and facilitates OMH and OASAS initiatives in this area

3

Timeline

New York State (NYS) Office of Alcoholism & Substance Abuse Services (OASAS) and Office of Mental Health (OMH) convene a Co-occurring Disorders (COD) Task Force (2007)

May, 2007

The NYS COD Task force makes recommendationsDecember, 2007

The Directors of licensed substance abuse and mental health programs receive two letters with recommendations for integrating services for COD from the Commissioners of OASAS and OMH

June 20 & July 31, 2008

The New York State Health Foundation (NYSHealth) funds the Center for Excellence in Integrated Care (CEIC, pronounced “seek”)

November 1, 2008

4

What does CEIC do?

Engages Leadership

Performs on-site assessments

Presents site reports

Conducts provider forums

Builds collaborations and informal networks

Holds Peer Recovery Workshops

Supplies ongoing support, guidance, and consultation

Links programs to resources, such as FIT, TIP 42, and related in-service training, as well as other trainings and curricula

Provides technical assistance (hands-on, intensive, and longitudinal)

5

Uses DDCA[MH]T (Dual Disorder Capability in Addiction Treatment

and Dual Disorder Capability in Mental Health Treatment)

Samples individual clinics within regions

Employs direct onsite observation

Scores and reports on 7 domains and overall

Makes specific recommendations to raise capability

CEIC Assessment Methods

6

Improving Co-occurring Capability Recommendations by DDCA[MH]T Dimensions

Dimensions of

CapabilityLevels of Capability

SA/MH only Capable Enhanced

I Program Structure Program mission, structure and financing, format for delivery of co-occurring services

II Program Milieu Physical, social and cultural environment for persons with mental health and substance use problems

III Clinical Process:[screening &] Assessment

Processes for access and entry into services, screening, assessment &diagnosis

IV Clinical Process: Treatment

Processes for treatment including pharmacological and psychosocial evidence-based formats

V Continuity of Care Discharge and continuity for both substance use and mental health services, peer recovery supports

VI Staffing Presence, role and integration of staff with mental health and addiction expertise, supervision process

VII Training Proportion of staff trained and program’s training strategy for co-occurring disorder issues

7

Series11

1.5

2

2.5

3

3.5

4

4.5

5

Dual Disorder Capability

Total Score Se-ries1

Program Structure

Program Milieu

Assessment Treatment Staffing TrainingContinuity of Care

2.702.48 2.50

3.06

2.532.76

3.09

2.47

Enhanced

Capable

Basic

Scores based on DDCA[MH]T = Dual Diagnosis Capability in addiction [Mental Health] Treatment Index

(N=300)

Transformation of the Service System may be said to occur when the majority of outpatient

clinics are rated capable or above

8

Program Structure

Recommendations Update agency mission statement (or develop

a program service statement) to reflect that co-occurring services are provided

Ensure that the program’s licensure agreement (or state permit) identifies the target population as individuals with substance related disorders (for addiction clinics) or mental health disorders (for mental health clinics) but does not restrict the program from treating individuals with co-occurring mental disorders or substance use disorders, respectively

Demonstrate that your program’s system of care meets the definition of collaboration; that is, shared responsibility for treating a person with co-occurring conditions, involving regular and planned communication, and shared progress reports or memoranda of agreement

1

2

3

4

5

DDCA[MH]T Score

2.48

Enhanced –

Capable –

Basic –

Program Structure

9

1

2

3

4

5

Program Milieu

Recommendations Expect and welcome clients with both

disorders

Ensure that materials for both substance related and mental disorders are posted and distributed

Engage in a discussion with staff regarding "attitudes and values" towards treatment of co-occurring disorder

Program Milieu

2.50

Enhanced –

Capable –

Basic –

DDCA[MH]T Score

10

1

2

3

4

5

DDCA[MH]T Score

Screening (one item from Assessment Domain)

Recommendations

Clinical Process — Screening (one item from Assessment Domain)

Implement one of the state-recommended standardized screening instruments (these are all free, brief, and do not require clinical expertise to administer)

Establish a protocol that will direct all those with a positive score on the screen to an integrated assessment

Separate the screen from the assessment protocol; the screen should drive the assessment, but it is not a diagnostic evaluation nor should it be used to determine severity of a mental health or substance use condition

3.24

Enhanced –

Capable –

Basic –

11

1

2

3

4

5

Assessment

DDCA[MH]T Score

Enhanced –

Capable –

Basic –

Recommendations

Clinical Process —Assessment

Provide a comprehensive assessment that covers all 12 recommended domains and includes a thorough substance use and mental health evaluation

Obtain diagnostic evaluation as part of the assessment process

Build on the stages of change for both disorders

Synthesize assessment information into main problem areas that need to be addressed

Use assessment data to inform the treatment plan

3.06

12

1

2

3

4

5

DDCA[MH]T Score Recommendations

Clinical Process — TreatmentIntegrated COD Services

Allow the free expression and discussion of co-occurring problems in group and individual sessions

Ensure inclusion of mental health and substance use content in all groups

Create a “home” for co-occurring disorders in the treatment schedule (i.e., offer a psycho-educational class for COD and a dual recovery group)

Provide supervision and coaching to increase staff competency in COD

2.53

Enhanced –

Capable –

Basic –

Treatment: Integrated COD Services

13

Recommendations

Clinical Process — TreatmentEvidence Based Interventions

Organize treatment with a stage-wise approach

Build staff competencies in Motivational Interviewing

Employ existing trauma curriculums; for example, Seeking Safety and Trauma Recovery & Empowerment Model (TREM)

Offer Wellness Self-Management curriculum to integrate co-occurring content further

Gradually introduce other NYS recommended evidence-based interventions

0%

20%

40%

60%

80%

100%

Data from OASAS Local Service Plan (LSP) Survey

24%

Evidence-based Interventions

14

1

2

3

4

5

Continuity of Care

DDCA[MH]T Score Recommendations

Continuity of Care

Ensure that the discharge plans address both the substance use and mental health disorders

Encourage and arrange connections to community support groups during treatment and as part of discharge planning (e.g. Double Trouble in Recovery, Dual Recovery Anonymous)

Provide a supply of medication sufficient to span from discharge until continuing treatment has been established

2.76

Enhanced –

Capable –

Basic –

15

1

2

3

4

5

Staffing

DDCA[MH]T Score Recommendations Ensure that at least one direct care staff

member has mental health and substance use competency or licensure

Provide on–site clinical supervision sessions that include a focus on co-occurring disorders

Ensure that team meetings and case reviews incorporate co-occurring disorders

Staffing

3.09

Enhanced –

Capable –

Basic –

16

1

2

3

4

5

Training

DDCA[MH]T Score Recommendation Demonstrate that the program has a

written training plan

Maintain and enhance staff competencies in co-occurring services using up-to-date literature, films, and other media, as well as in-service and external trainings

Train staff in specialized treatment approaches and pharmacotherapy

Training

2.47

Enhanced –

Capable –

Basic –

17

Recommendation

Training —Focus on Integrated Treatment

Description of FITThis training helps practitioners gain a firm foundation in evidence-based

integrated treatment for COD including screening and assessment, stage-wise treatment, motivational interviewing, and more. Additional modules help clinical supervisors develop their supervision skills and guide agency leaders through changes to ensure sustainability of integrated treatment.

Along with learning modules, CPI (the Center for Practice Innovation) offers inline implementations supports through webinars, “Ask the Expert” forums, and discussion threads.

The training is comprised of 35 individual modules developed alongside experts at the Dartmouth Psychiatric Research Center

Urge staff to enroll in FIT (Focus on Integrated Treatment) online learning

http://www.practiceinnovations.org/CPIInitiatives/FocusonIntegragedTreatmentFIT/tabid/99/Default.asp

18

1. Introduction

2. Definitions, Terms, & Classification

3. Systems for COD

4. Keys to Successful Programming

5. Assessment

6. Strategies for Working with Clients with COD

7. Traditional Settings & Models

8. Special Settings & Models

9. Special Settings & Specific Populations

10. A Brief Overview of Specific Mental Disorders & Cross-Cutting Issues

11. Substance-Induced Disorders

http://store.samhsa.gov/product/SMA08-3992

Recommendation

Training — TIP 42

Refer to and use TIP 42 and its associatedin-service training curriculum

Description of TIP 42

19

Improving Co-occurring Capability — Quick Guide

1. Provide educational material for both disorders

2. Revise agency mission statement or develop a program service statement

3. Implement one of the NYS-recommended standardized screening instruments

4. Use assessment data to inform the treatment plan

5. Allow co-occurring concerns to be expressed and discussed in all group and individual sessions

6. Ensure that all groups include mental health and substance use content

7. Offer a psycho-educational class on COD and a dual recovery group to create a “home” for co-occurring disorders in the program schedule

8. Include both substance use and mental health treatment in discharge plans and provide sufficient medication to last until continuing care has been established

9. Urge staff to enroll in FIT web-based learning

10. Refer to and use TIP 42 and its associated training curriculum

10 recommendations for Getting to “Capable”

Easy to Employ & Conserves Resources

20

Improving Co-occurring Capability – Quick Guide

Clinical Process: Screening & Assessment

Clinical Process: Treatment

Continuity of Care

Staffing

Training

Program Structure1. _________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________

Program Milieu1. _________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________

1. _________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________

1. _________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________

1. _________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________

1. _________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________

1. _________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________

Clinic Name: Your Name: Email: Phone:

21

Taskforce and Commissioners’ Recommendations

Screening Instruments

For mental disorders:

Modified MINI Screen (MMS)

Mental Health Screening Form III (MHSF III)

K6 Screening Scale (K6)

For substance use disorders:

Modified Simple Screening Instrument for Substance Abuse(MSSI-SA)

CAGE Adapted to Include Drugs (CAGE-AID)

Alcohol, Smoking, and Substance Involvement Screening Test – v3(ASSIST v3)

Assessment Domains

Presenting problem[s] Current symptoms &

functioning Background Individual history Substance use Mental health Medical history Mental status

examination Client perception[s] Cultural and linguistic

considerations Supports & strengths Diagnostic

impressions on 5 DSM Axes

Evidence-based Interventions

For both disorders: Approved medications

For substance use disorders:

Evidence-based individual, group, couples, and family treatments –including• motivational

enhancement• CBT• 12-step facilitation• behavioral couples &

family therapy• contingency management

For mental illness: CBT, medication

For serious mental illness:

Managing illness (IDDT, education, medication, CBT) family psychoeducation, supported employment, social skills training

Peer support

22

Series10

2

4

6

8

10

12

Series1

0

50

100

150

200

250250

200

150

100

50

0

Training & Technical Assistance ActivitiesYear 1,Year 2, Year 3(4th Quarter of Year 3 is projected)

14 Lea

dership

Forums

22 Bldg Cap

abilit

y

Forums

7 Bldg Rec

overy

Workshops

451 D

DCA[MH]T

asse

ssmen

ts

Year 1 (Nov ’08 - Dec ’09) Year 2 (Nov ’09 - Oct ’10)Year 3 (Nov ’10 – Oct ’11)

5 5

4

3

8

11

0

3

4 86

165

200

DDCA[MH]T = Dual Diagnosis Capability in Addiction [Mental Health] Treatment Index

23

CEIC TA Serviceshave been provided in about ¾ of the state’s regions/counties

24

Series11

1.5

2

2.5

3

3.5

4

4.5

5

Dual Disorder Capability

Total Score Se-ries1

Program Structure

Program Milieu

Assessment Treatment Staffing TrainingContinuity of Care

2.702.48 2.50

3.06

2.532.76

3.09

2.47

Enhanced

Capable

Basic

Scores based on DDCA[MH]T = Dual Diagnosis Capability in addiction [Mental Health] Treatment Index

(N=300)

Closer to Capable

than to Basic

25

Dual Disorder Capability— Percentage Capable

Scores based on DDCA[MH]T = Dual Diagnosis Capability in Addiction [Mental Health] Treatment Index

1

2

2.5

3

1.5

3.5

4

4.5

5

7%

22%

30%

6%

15%

21%

43% are near or above Capable

Enhanced

Capable

Basic

26

Bi-annual OASAS EBP Survey

Surveydesigned to obtain EBP integration by implementation stages (Fixsen et al.)

Added items on COD in collaboration with CEIC (and NKI) to assess COD practices

Sent to all OASAS certified programs

Rated on a 5- point implementation scale5. Sustainability4. Innovation3. Implementation2. Installation1. Exploration

Employs drop-down menu of additional questions to increase the accuracy of reporting

Response rate 96% of all licensed programs

27

Local Services Plan (LSP) Survey Tool(sample page)

28

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

ScreeningAssessment

Integrated Ser-vices

MotivationalInterviewing

Cognitive Be-havioral Ther-

apy

Contingency Management

Behavioral Couples Ther-

apy

Mutual Self-Help Group

Psychotropic Medication

Evidence-Based Practices and Evidence-Based

Interventions: Level of Implementation

Level of Implementation Scale:5 = Sustainability4 = Innovation3 = Implementation2 = Installation1 = Exploration0 = Not applicable (hasn’t moved to implement at all)

Practices Interventions

29

Screening, Assessment, Integrated ServicesBased on OASAS Survey (Level 5)

30

Total Motivational Interviewing

Cognitive Behavioral Therapy

Behavioral Couples Therapy

Mutual Self-help

ContingencyManagement

23%

About ¼regularly employ evidence-based

interventions

Evidence-Based Treatment for CODBased on OASAS Survey (Level 5)

31

Comparative Survey Results

32

Strategic Plan — Reach & Penetration

• DRCs

• FIT

• Regional / County Networks

Direct (“hands-on”)

TechnicalAssistance

amplifies Direct TA and promotes Sustainability

The strategic plan to reach & penetrate more than 1,000 out-patient substance abuse & mental health clinics over 4 years

33

1) Follow up DDCA[MH]T survey on representative sample

2) Follow up on OASAS survey — planned for 2012

3) Analysis combining these data sources (as briefly illustrated here)

4) Focus groups

5) Case studies

6) Brief web-based survey

Evaluation PlanHow will we know the system status?

34

Integrated Services – Nassau County to integrate services both within clinics and across the service system

Video – creating a video on building COD capability in the areas of Screening, Assessment and Evidence-Based Practices called “Getting to Capable”

Manuscript – writing a descriptive study of the current status of the system for publication

New Instrument – developing and refining an instrument to measure recovery-oriented services integration with NYAPRS

New Instrument – developing and field testing an instrument withDr. Mark McGovern to measure the degree to which primary health care services have been integrated with mental health and substance use interventions. This has particular significance for health care reform.

Recent Developments

35

There exists a clear and increasingly positive picture of the status of OMH and OASAS outpatient clinics regarding evidence based practices and interventions 45% for screening

40% for assessment

⅓ for integrated services

¼ for evidence based interventions

The potential for advancement is greatest in the domains of Program Structure, Milieu, Treatment, Training and Continuity of Care, areas where certain improvements are considered to be fairly easy to achieve given the current status of staffing and resources

Transformation of the Service System may be said to occur when the majority of outpatient clinics are rated capable or above

Summary

OMH and OASAS outpatient clinics are moving toward a COD capable status

36

The project is significant in its:

Promise of improving the health of NYS residents with co-occurring conditions

Potential to reduce health disparities

Ability to inform allocation of resources

Capacity to effect system transformation in the delivery of services

Implications for health care reform: Identifying capable programs Illustrating methods and approaches for advancing

integration

Conclusion

37

Contact InformationStanley Sacks, PHD, DirectorCenter for the Integration of Research & Practice (CIRP) & Center for Excellence in Integrated Care (CEIC)

National Development & Research Institutes, Inc. (NDRI)

71 W 23rd Street, 8th Floor

New York, NY 10010

TF 877.888.6677 tel 212.845.4400 fax 212.845.4650

www.nyshealth-ceic.orgwww.ndri.org

Michael Chaple, PHD, Deputy DirectorCenter for the Integration of Research & Practice (CIRP) & Center for Excellence in Integrated Care (CEIC)

National Development & Research Institutes, Inc. (NDRI)

71 W 23rd Street, 8th Floor

New York, NY 10010

TF 877.888.6677 tel 212.845.4400 fax 212.845.4650

www.nyshealth-ceic.orgwww.ndri.org

ChackuMathai, CPRP, Associate Executive DirectorNew York Association of Psychiatric Rehabilitation Services

1 Columbia Place, 2nd Floor

Albany, NY 12207

tel 518.436.0008

www.nyaprs.org

CEICreceives support (awards 2008-2496857 & 2009-3426912) from the New York State Health Foundation