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CALIFORNIA MENTAL HEALTH PLANNING COUNCIL

October 14, 2009

ELIZABETH OAKES, MFT

CHIEF, ADULT SYSTEM OF CARE

STANISLAUS COUNTY BEHAVIORAL HEALTH & RECOVERY SERVICES

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Co-Occurring Treatment Stanislaus County Behavioral

Health and Recovery Services 1998 – 2009

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In 1998, Alcohol and Other Drug (AOD)

services were decentralized and moved into shared space within 5 Mental Health Outpatient Regional Teams. Services were co-located by treatment continued to be parallel.

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In 2004, Stanislaus County – BHRS entered into a two-year grant through CIMH to study implementation of Integrated Dual Diagnosis Training in California. CIMH provided training in this model for two years.

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Organizational Context

How IDDT fits for BHRS:

-Committed to integrated services BHRS

-Integrated system isn’t integrated treatment

-Established experience with co-occurring Tx

-Valued EBP aspect

-Interested in ‘implementation’ aspect

-High mortality rate

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STAGE

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STAGES OF

CHANGE

Pre-Contemplation

Contemplation

Preparation

Action

Maintenance

STAGES OF

IMPLEMENTATION

Unaware or uninterested

Consensus building

Motivating

Implementing

Sustaining

Steps: 1 Ask important questions

Conduct a needs assessment

Define your rationale

Conduct a baseline fidelity review

Maintain oversight

2 Begin the change process

Develop awareness of available options

Identify stake-holders

Develop a baseline fidelity action plan

Monitor fidelity

3 Identify current practices and rationales

Build consensus Develop stage-wise interventions

Monitor outcomes

4 Examine your mission, values, goals, and vision

Find your “champions”

Acquire and integrate training

Network with others

5 Check it out Identify financial resources

Engage in clinical consultation

Provide ongoing training

6 Engage technical assistance

Assemble a steering committee

Provide stage-wise interventions

Engage in ongoing consultation

7 Assess the pros and cons

Conduct a readiness assessment

Develop and monitor outcomes

Expand services

8 Develop informed consent and consensus

Decide to implement or not

Continue to educate and train stakeholders

Transform the organizational culture

9 Explore concerns Recruit a team leader

Address barriers

10 Plan to start small Address unintended consequences

11 Assemble the multi-disciplinary service team

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Begin an implementation plan

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Organizational Context How IDDT fits for BHRS (continued)

-High co-morbidity-High treatment failure rate-Cost of not serving for system-Highly underserved-Co-occurring conditions often used as exclusion criteria, rather than inclusion criteria

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Benefits of Integrated Recovery- Saves money- Helps staff motivation- Impacts long-time ‘stuck’ clients- Stage-based treatment- Formulation helps consumers understand how 2

conditions creates a 3rd condition- Recovering peers from either MH or AOD can

support each other- DRA sustained- Recognition with in AOD for need of specialized

track

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FORMULATION

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Integrated Dual Diagnosis Treatment (IDDT)

1. Integrated Assessment of Dual Diagnosed (DD) Clients2. Integrated Treatment Plan3. Multidisciplinary Team4. Integrated Substance Abuse Specialist5.5. Stage-Wise InterventionsStage-Wise Interventions6. Access for IDDT Clients to Comprehensive DD Services7. Time-Unlimited Services8. Outreach9.9. Motivational InterventionsMotivational Interventions10. Substance Abuse Counseling

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Integrated Dual Diagnosis Treatment (IDDT) continued

11. Group DD Treatment

12. Family Education and Support on DD

13. Participation in Alcohol & Drug Self-Help Groups

14. Pharmacological Treatment

15. Interventions to Promote Health

16. Secondary Interventions for Substance Abuse Treatment Non-Responders

17. High Intensity Services

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STAGE-WISE STAGE-WISE INTERVENTIONSINTERVENTIONS

RECOVERY DIALOGUE

MOTIVATIONAL MOTIVATIONAL INTERVENTIONSINTERVENTIONS

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FOCUS ON RECOVERY

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Client RecoveryRecovery Care PlanPage 1 and 2 to be completed by consumer  1. My recovery goals are: _____________________________________________________ __________________________________________________________________________   2. The people who are important in my life believe in my RecoveryRecovery (circle one)  Strongly Agree Agree Disagree Strongly Disagree  3. How can we assist you as partners in your recoveryrecovery _____________________________ _________________________________________________________________________ _________________________________________________________________________  4. What keeps you from reaching your goals? ____________________________________ _________________________________________________________________________ _________________________________________________________________________  5. My diagnosis is: __________________________________________________________  6. Please list the medications your receive from us and a brief reason you take them

_____________________________________________________________________ _____________________________________________________________________

_________________________________________________________________________ (Staff: Please attach a copy of the medication sheet for complete list of all medications.)  

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Client Recovery Care Plancontinued

 Things about my life  7. Something you should know about me is _______________________________________  8. Something really important to me is ___________________________________________  9. When it comes to my culture please be sensitive about ____________________________  10. We all have gifts in life. My gifts are: __________________________________________ 11. My best place to live_________________________ Where I live works for me Yes No  12. My best way to spend time____________________ I like how I spend my time Yes No  13. My most ideal job would be: _________________I would like employment help Yes No  14. I need help with budgeting and money Yes No  15. What gives me hope is_____________________________________________________ __________________________________________________________________________ __________________________________________________________________________

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Client Recovery Care Plancontinued

 My Health  16. My health goals are: _______________________________________________________  ___________________________________________________________________________ _17. I see my dentist on a regular basis: Yes No Don’t Have One  18. I see my Primary Care Doctor on a regular basis: Yes No Don’t Have One  19. In the future I would feel comfortable receiving all of my medication services from my  Primary Care Doctor: Yes No Primary Care Doctor Name_________________________ 20. Because specialty mental health services generally are time limited, do you have any  discharge / graduation concerns? Yes No Comment:____________________________  21. Have you had a problem with alcohol or drugs in the past: Yes No  22. Currently use alcohol or drugs: Yes No If yes, do you want help to stop using them? Yes No

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Client Recovery Care Plancontinued

 How My Mental Illness Affects Me

23. Please check any area that your mental illness interferes with:

� Self care and health includes taking care of yourself daily How much? � None � Mild � Moderate � Severe

� Things I want to do like work, school, volunteering, hobbies, job training etc. How much? � None � Mild � Moderate � Severe

� Relationships with family, friends, peers, co-workers, health care staff, etc. How much? � None � Mild � Moderate � Severe

Progress in Recovery Goal(s)

Since working on my life goals on my own or since my last Recovery Care Plan, I have had the following Improvements or Setbacks:

Much Slightly No Change Some Much Worse Worse Improvement Improved

Home or where I live Recovery Goals

Use of Support System/Free Time

Physical Health

Effects of My Illness

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Client Recovery Care Plancontinued

 

24. What I will start doing now towards my recovery goalrecovery goal(s)_____________________________

25. What I need from my treatment team now________________________________________

26. What I need from other people in my life now_____________________________________

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Stanislaus County Behavioral Health and Recovery ServicesAdult System of Care

 Stages of Mental Health Recovery and Treatment9/2004

Crosswalk with Milestones, Stages of Change and Stages of Treatment

Consumer Generated Milestones in Recovery from Mental Illness: (Stanislaus County BHRS)

Stages of Treatment:

Stages of Change:

Stages of Recovery Oriented Mental Health Treatment: (Stanislaus County BHRS)

1. Beginning awareness of problem(s) within oneself.

“I begin to recognize my inner distress but may be unable to identify what it is.”

Engagement Precontemplation

1. Pre-Engagement

2. Engagement/ Outreach

2. Willingness to discuss problem and accept help.

“I begin to examine my distress with the help of others.”

Contemplation 3. Contemplation/

Exploration

3. Begin to believe that hope and recovery are possible.

“I choose to believe that hope exists.”

Motivation

Preparation 4. Recovery

Awareness

4. Coping with symptoms and examining life circumstances.

“I start overcoming those symptoms that keep me from examining what is important to me in life.”

5. Takes action step(s) directed toward recovery.

“I voluntarily take some action toward recovery.”

5. Stabilization and Beginning Recovery

6. Actively participates in mutual aid, peer support, and/or treatment.

“I start to enjoy the benefits of mutual recovery.”

Active Treatment Action

6. Active Recovery

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Stanislaus County Behavioral Health and Recovery ServicesAdult System of Care

 Stages of Mental Health Recovery and Treatment9/2004

Crosswalk with Milestones, Stages of Change and Stages of Treatment

- Continued -

7. Takes ownership / responsibility for one's own recovery.

“I am responsible for my own recovery.”

7. Relapse Prevention

8. Being of service to others strengthens one's own recovery.

“Yes, helping others strengthens my recovery.”

Relapse Prevention Maintenance 8. Maintaining

Recovery

NOTE: Milestones and Stages of Mental Health Treatment do not exactly line up because the Milestones were developed first from a consumer’s point of view; the Stages of Mental Health Treatment were then developed from the Milestones but were adjusted slightly to be consistent with the SATS format and to have two stages for each general Stage of Treatment.

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LEVEL OF CARE

Recovery Recovery Maintenance Health Management

Low Intensity Community Based Services

High Intensity Community Based Services

Medically Monitored Non-Residential Services

Medically Monitored Residential Services

Medically Managed Residential Services

  1 2 3 4 5 6

 

DIMENSIONSSURVEYED

Risk of Harm

Functional Status

Co-Morbidity

Recovery Recovery EnvironmentEnvironment “Level of Stress”

Recovery Recovery EnvironmentEnvironment “Level of Support”

TreatmentTreatment & Recovery Recovery HistoryHistory

Engagement & Recovery Recovery StatusStatus

 

Level of Care Utilization System (LOCUS)

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Team Structure

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Stage-Wise Case Management Case management is the central clinical intervention for the community

treatment of clients with dual disorders.

Considering the range of potential treatment options, the complexity of identifying and prioritizing treatment goals, and the limited cognitive capacity of many clients with dual disorders (due to the mental illness, the effects of substances, or their combination), one clinician needs to take responsibility for ensuring that clients' needs are assessed, systematic treatment planning takes place, interventions are delivered in a coordinated fashion as intended, and treatment has its desired effects (or if not, treatment is suitably altered).

The case manager works with the client and serves this vital role, and therefore is the glue that holds together and ensures the integration of the various components of treatment for dual disorders.

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Motivational Interviewing All interactions with DD clients are based on

motivational interviewing that includes:

Expressing empathyDeveloping discrepancy between goals and

continued useAvoiding argumentationRolling with resistanceInstilling self-efficacy and hope

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What is Motivational Interviewing?(continued)

Motivational Interviewing is not just a collection of techniques, but a way of being with a client.

----Miller and Rollnick

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BRIAN MADEAROSARTIST

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