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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LearningObjective 1

Evaluate the need forand benefits of amultidisciplinary treatmentteam for patients withalcohol dependence



LearningObjective 2

Integrate 12-stepsand treatment ofco-occurring disorders



LearningObjective 3

Integrate the use ofmedications into atraditional abstinence-based treatmentprogram



Creating the MultidisciplinaryIntegrated Treatment Team:

A CEO's Perspective

Supported by an independent educationalgrant from Cephalon, Inc., and Alkermes, Inc.



Susan K. Blank, MD

VP Clinical Services

Caron Treatment Centers



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



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



Integration: Level 1

Multidisciplinary Treatment Team



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



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



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



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



A multidisciplinaryapproach is key to

successful treatment ofalcohol dependence and

other drug addiction



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



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



BuckyBall


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




Integration of 12-Step Principlesand Treatment of Patients with

Co-Occurring Disorders



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


Title safe - 8% margin1. Lee F. If Disney Ran Your Hospital 9 Things You Would Do

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



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



The key to successis teamwork!

The key to successfulteamwork is supervision


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



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



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




Integration of medication managementinto a traditional abstinence-based

program



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



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



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


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



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



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



Education is a Core Value


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



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


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


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


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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