creating the multidisciplinary integrated treatment team
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Creating the MultidisciplinaryIntegrated Treatment Team:
A CEO's Perspective
Supported by an independent educationalgrant from Cephalon, Inc., and Alkermes, Inc.
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CME Outfitters, LLC,is the accredited providerfor this neuroscienceCME
continuing educationactivity.
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CME Outfitters, LLC,gratefully acknowledges anindependent educational
grant from Cephalon, Inc.,and Alkermes, Inc., in
support of this CE activity.
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The course guide for thisactivity includes slides,disclosures of faculty
financial relationships,and biographical profiles.
For additional copies ofthese materials, please
visit neuroscienceCME.comor call 877.CME.PROS.
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To receive CE credits for thisactivity, participants may
complete the post-test andevaluation online at
neuroscienceCME.com/test
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The faculty have beeninformed of their
responsibility to discloseto the audience if they will
be discussing off-labelor investigational uses(any use not approvedby the FDA) of products
or devices.
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LearningObjective 1
Evaluate the need forand benefits of amultidisciplinary treatmentteam for patients withalcohol dependence
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LearningObjective 2
Integrate 12-stepsand treatment ofco-occurring disorders
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LearningObjective 3
Integrate the use ofmedications into atraditional abstinence-based treatmentprogram
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Creating the MultidisciplinaryIntegrated Treatment Team:
A CEO's Perspective
Supported by an independent educationalgrant from Cephalon, Inc., and Alkermes, Inc.
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Susan K. Blank, MD
VP Clinical Services
Caron Treatment Centers
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1. Brady KT, et al. Curr Psychiatry Rep 2007;9:374-380.2. Mannelli P, Pae CU. Curr Psychiatry Rep 2007;9:217-224.3. SAMHSA. Evidence-Based practices for Co-Occurring Disorders -
Interventions Adults with Co-Occurring Disorders, 2002. Available at:http://www.samhsa.gov/reports/congress2002/chap4iacd.htm.Accessed February 24, 2008.
Why Change Is Needed?
Today’s patients and their families arestruggling with serious addictions, co-occurring psychiatric disorders, and oftensignificant medical comorbidities1,2
Patients and their families need help toheal their physical, emotional, and spiritualdamage resulting from the disease ofaddiction
This healing takes place best within amultidisciplinary treatment team3
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IntegrationThree Levels
Multidisciplinary treatment team
Integration of 12 steps and treatmentof co-occurring disorders
Integration of the use of medicationsinto a traditional abstinence-basedtreatment program
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1. Shulman GD. Continuing Care 1994;13:27-33.2. McLellan AT, McKay JR. Components of Successful Addiction Treatment.
In: Principles of Addiction Medicine, 3rd edition, Graham AW, SchultzTK, Mayo-Smith MF, Ries RK, Wilford BB (Eds). American Society ofAddiction Medicine. Baltimore: Lippincott Williams & Wilkins. 2007,pp. 436-437.
Why a Multidisciplinary Team
Individualized, assessment-driventreatment planning emphasizes the need toprioritize and plan for the patient’s needsover a continuum of care1
Studies have shown that patients withcomorbid psychiatric problems benefit fromprofessionally delivered psychotherapy,psychotropic medications, and greaterintensity of structure2
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Why Change Is Needed?
Until recently, at Caron, medicine,nursing, psychology, psychiatry,chaplains, and research have all beenconsulting, “ancillary” services totreatment units
The “psychology pool” provided evaluationsas requested after doing initial psychologicalevaluation
Ancillary services made“recommendations” to treatment teamrather than assuming more directresponsibility for each patient’streatment
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Challenges
History of Caron as a 12-steptreatment center based on a socialmodel of treatment
Many disciplines “speaking” differentlanguages
Addiction counselors speaking thelanguage of recoveryPsychologists speaking “psycho-babble”
Inertia of any large organization
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Challenges
Fear of Change
Misunderstanding roles
We don’t know what we don’t know
Alumni worried about what willhappen to Caron as a 12-stepprogram
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A multidisciplinaryapproach is key to
successful treatment ofalcohol dependence and
other drug addiction
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Team Members
There is a need to expand the idea ofteam members being the only peoplecurrently in the room
The treatment team is everyone andanyone who has a stake in theoutcome of the patient
The patient is at the center and themost important member of the team
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Patient andPatient andAddictionsAddictionsCounselorCounselor
SpiritualSpiritualStaffStaff
ReferralReferral- Outpatient Rx- Outpatient Rx- Interventionist- Interventionist- PCP- PCP
LawyerLawyerandand
LegalLegalSystemSystem
NutritionistNutritionist
MedicalMedicalStaff/Staff/
Doctors &Doctors &NursesNurses
Psychology/Psychology/PsychiatryPsychiatry
StaffStaff
PastPastTreatmentTreatmentProvidersProviders
OtherOthermembers ofmembers of
assigned unit/assigned unit/Other CaronOther Caron
Staff/RecStaff/RecStaffStaff
EmployerEmployerEAPEAPSAPSAP
Family,Family,SponsorSponsor12-Step12-StepGroupGroup
SignificantSignificantothersothers
Clinical Coordinator
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Title safe - 8% margin1. Big Book Study: Alcoholics Anonymous. 4th Chicago Big Book Seminar
at Schiller Park, IL. May 21-23, 1993. Presented by Charlie P (fromMaysville, AR) and Joe McQ (from Little Rock, AR).
Example: Psychologists
Psychologists werethe first group to beintegrated
Asked them tocheck their egos atthe door
Trained themextensively in 12-step principles, i.e.“Joe and Charlie BigBook Study”1
Asked them to bevulnerable andpresent their ownvideotaped sessionsto the weekly peergroup supervision
Asked them to learnfrom others
Big steps:Big results
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Integration: Level 2
Integration of 12-Step Principlesand Treatment of Patients with
Co-Occurring Disorders
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1. Project MATCH Research Group. J Stud Alcohol 1997:58:7-29.
Issues
Multidisciplinary teams need acommon language
They also need a common evidence-based treatment modality to allowpeer supervision1
Silos must come downProblems need to be addressed at thelevel of most direct responsibility
Expectations must be made clear
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Differently. Bozeman, MT: Second River Healthcare Press, 2004,pp 27-28.
Common Goal Is Needed
Safety first, for patients, staff, andthe institution1
Excellence in patient care
Continue always to strive to be better
Kindness and compassion for all
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1. Powell DJ, Brodsky A. Clinical Supervision in Alcohol and Drug AbuseCounseling: Principles, Models, Methods. San Francisco: Jossey-Bass, 2004.
2. Miller WR, Rollnick S. Motivational Interviewing, 2nd Ed. New York: TheGuilford Press, 2002.
First Things First
Leadership developed a detailedwritten philosophy of treatment
Group supervision was introduced andpracticed for 2 years, using the DavidPowell method1
Leadership decided on an evidence-based treatment modality to teach allmembers of the team: MotivationalInterviewing2
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The key to successis teamwork!
The key to successfulteamwork is supervision
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Title safe - 8% marginPowell DJ, Brodsky A. Clinical Supervision in Alcohol and Drug AbuseCounseling: Principles, Models, Methods. San Francisco: Jossey-Bass, 2004.
Helps cliniciansaddress issues oftransference andcounter transference,which they may havewith their patientsand families
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1. Center for Substance Abuse Treatment. Substance Abuse Treatment forPersons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP)Series 42. DHHS Publication No. (SMA) 05-3922. Rockville, MD: SubstanceAbuse and Mental Health Services Administration, 2005.
ExpectationsTreatment Team
We expect each memberof the treatment team tohave a workingunderstanding of the 12steps and co-occurring disorders1
Helping our patients understand how to use12-step meetings, work the steps, understandsponsorship, and find and define their HigherPower are the primary objectives of ourtreatment philosophy
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ExpectationsTreatment Team
We expect our treatmentteam members to respectand assist each other inthe delivery of care to ourpatients and their families
The addiction counselor is the primarytreatment provider to the patient
Other disciplines work with the patient bothdirectly and indirectly to accomplish treatmentgoals and objectives
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Integration: Level 3
Integration of medication managementinto a traditional abstinence-based
program
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History of Treatment Evolution
Caron opened in 1957as a 12-steptherapeuticcommunity forpatients with alcoholdependence
1962, firstpsychologist on staff,Gerald Shulman, MA
In 1964, first MDcame on board totreat complications ofalcohol dependence,Robert Denby, MD
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History of Treatment Evolution
Began to treat drugaddiction in 1969
In 1975, Caron openedthe first freestandingdetox unit in USA
1978, began to referpatients out to localpsychiatrist
First full-timepsychiatrist, Susan K.Blank, MD, hired in2007 as VP of ClinicalServices
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1. Pinta ER. Am J Psychiatry 2007;164:174.
Example: Quetiapine
Quetiapine, introduced byAstraZeneca in 1997
FDA approved quetiapineto treat depressiveepisodes associated withbipolar disorder, acutemanic episodesassociated with bipolar Idisorder, andschizophrenia. It is oftenprescribed to treatunapproved off-labelhealth problems such asinsomnia, depression, andanxiety
Caron MDs introduced theuse of quetiapine for thetreatment of anxiety andinsomnia with some staffresistance
In 2005, initial reports ofabuse coming out ofprisons, 2007 Letter tothe Editor1
In-house study onCaron’s use of quetiapine
Caron’s Department ofMedicine decided not touse quetiapine off-label
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Title safe - 8% margin1. Caron has several ongoing research studies re: cravings, such as
Cravings and Menstrual Cycle, Cravings and Spirituality, Cravings thruthe Continuum of Care.
Example: Long-ActingInjectable Naltrexone
April 14, 2005, FDA approvedlong-acting injectablenaltrexone for the treatmentof alcohol dependence inpatients who are able toabstain from alcohol in anoutpatient setting prior toinitiation of treatment that ispart of a comprehensivemanagement program thatincludes psychosocial support
Caron’s Professional AdvisoryBoard recommends use
Caron’s Board of Directorsaccepts recommendations
Multiple staff trainings, withmany questioning the usewithin an abstinence-basedprogram
Questionnaires for patients toreview cravings given weeks2 and 4 of treatment1
Increased referrals foranticraving medications toMedical Department
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Lessons Learned
Some changes can be evolutionary,others must be revolutionary
“Incrementalism is innovation’s worstenemy” - Nicholas Negroponte
No one likes change
Nothing beats direct observation whenchanging culture
The higher up the food chain you are, theless likely you will hear about a problemwhen it would be most easily solved
Hire people who have different skill setsthan yours
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Lessons Learned
The best ideas come from the linestaff who actually have to do the work
Input from stake holders is vital
Inclusion of staff in the discussions ofchange help to generate buy in, evenif their opinion did not win the day
Make sure your vision is clearlystated, over and over and over again
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Title safe - 8% margin1. Recovery for Life. Caron-Comprehensive Addiction Treatment for Life.
Wernersville, PA, 2007.2. Alcoholics Anonymous World Services. New York, NY.
Education
Educate the patient about theirdisease1
Big Book and Twelve and Twelve2 arethe basis for our treatment andrecovery plan
Activities that illustrate the conceptsof recovery are most valued:
Ropes course to help patient understandthey can not do it aloneExperiential work at Center for SelfDevelopment for co-dependency issues
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1. Center for Substance Abuse Treatment. Substance Abuse Treatment andFamily Therapy. Treatment Improvement Protocol (TIP) Series, No. 39.DHHS Publication No. (SMA) 04-3957. Rockville, MD: Substance Abuseand Mental Health Services Administration, 2004.
Education
Educate the family about patient’sdisease and their disease1
Family education begins at admission,or even before
Linking families with families throughour PARENT NETWORK helps tosupport and educate them
Family programming is vital tosuccess
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Title safe - 8% marginCaron. Programs & Services: Student Assistance Programs.Available at: http://www.caron.org/programs.cfm/cat/ps-student.html.Accessed February 15, 2008.
Education
Educate the community
Community outreach is veryimportant
SAP (Student Assistance Program) atCaron in 209 schools, in 9 statesreaching over 35,000 kids, 1700educators, and over 1600 parents
Taking advantage of ourmultidisciplinary team to give lecturesand workshops
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Title safe - 8% margin1. Project MATCH Research Group. J Stud Alcohol 1998;59:631-639.2. Anton RF, et al. JAMA 2006;295:2003-2017.
Education
Educate the staff about advances intreatment1,2
Continuing education is veryimportant; each staff member has anindividual development plan
Staff have the ability to completeundergraduate and masters programson campus
Grand rounds, national speakers, andlectures are part of our commitmentto excellence
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Title safe - 8% margin1. Caron Treatment Centers: www.caron.org. Research projects tab onwebpage.
Education
Educate other healthcare providers
Training of family practice residents,psychiatry residents, and fellows
Full-time psychology interns
Internships for Masters-level clinicians
Research department studying allaspects of our treatment andoutcomes1
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