report on co-occurring disorders to california mental health planning council 10.15.2009 david...
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Report on Co-Occurring Disorders
to CaliforniaMental Health Planning
Council
10.15.2009
David Pating, MD
Overview
1. Update MHSOAC2. Report on Co-occurring Disorders
to MHSOAC3. Status: COD treatment in
California
Mental Health Services Act Prop 63 – passed 2004 by 54% electorate
1% assessment on incomes >$1M specifically to Transform Mental Health Care in California
Priorities: Client & Family Centered Cultural & Linguistically Competent Recovery & Wellness Focused Community Partnership Integrated Service Experience (Co-Occurring Disorders 11/09)
MHSOAC Staff and Officer Chair, Andrew Poat; Vice Chair, Larry
Poaster
Committees: Services: Pating, Gould Finance: Poaster Client & Family: Vega Cultural Linguistic Competency: Evaluation: Poaster, Van Horn
MHSOAC Annual Priorities In April 2009, the MHSOAC committed to the following annual
priorities…
1. To fund and execute all five MHSA programs2. Define “Transformation” and articulate its vision.3. Develop an integrated consistent approach to evaluate
the results of the MHSA and facilitate the adoption of the best practices across the entire community-based mental health system.
4. Adopt an approach for significantly reducing forms of mental health stigma and resulting discrimination towards those at risk and of living with mental illness and their families
5. Further define the roles and responsibilities of the Commission (in light of AB5xxx)
MHSOAC Current Priorities 1) Prudent Reserves: MHSOAC continues to
anticipate decreased revenue due to economic down turn from $1.6B (2008-9) to $900M in 2010. Fiscal discussions are underway to develop policy on maintenance and use of prudent reserves to smooth fiscal volatility.
2) Statewide PEI Projects: Guidelines are expected in December 2009 to implement 3 statewide projects: Student Mental Health Initiative, Stigma and Discrimination Reduction, Suicide Prevention. Alternative funding mechanisms have emerged to create collaborative entities to administer these programs.
3) Complaint Processes: DMH, in collaboration with MHSOAC is developing a comprehensive complaint review process that integrates county and state review.
Report on Co-Occurring Disorders
Transforming the Mental Health System
Through Integration
9.25.2008
To Achieve the Promise…
“To achieve the promise of community living for everyone, new service delivery patterns and incentives must ensure that every American has easy and continuous access to the most current treatments and best support services.”
-Presidents New Freedom Commission
on Mental Health (2003)
“Health care for general, mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body.”
--The Institute of Medicine, 2006
To Achieve the Promise…
Recommendations to Improve Treatment for Co-Occurring Disorders
Template for Integrating Services under the Mental Health Services Act
OAC Workgroup On COD
Following 6 months of hearings, the OAC Workgroup on Co-occurring Disorders Proposed in September 2008:
Transforming Mental Health
“If we want people with co-occurring disorders to recover,
we must promote systemic recovery.”-COD Report,
p.2
Co-occurring Disorders: Report Overview
1. Statement of MHSA Tenets “Whatever it Takes” “Integrated Services”
2. Key Findings Global Concerns Systemic Strengths
3. Core Recommendation “Promote COD Competency”
1. MHSA tenets include:
Effective services for people living with serious mental illnesses must include “whatever it takes” for recovery.
Services must be “integrated.”
“Whatever it takes”
Refers, in part, to flexible funding.
Flexible funding allows the use of funds for a wide array of clinical services and supports beyond what is normally allowed in categorical funding.
“Integrated Services”
Means mental health prevention and treatment are coordinated so that there is
“no wrong door” to receiving care.
Services should be concurrently delivered by a coordinated team of caregivers, often sharing single sites.
2a. Global Concerns Key Finding #1.
Approximately one half of people with a mental illness or a substance abuse disorder, also have the other condition.
These individuals have a co-occurring disorder (COD).
18
Mental & Substance Use Disorder
Epidemiology
L i f e t im e p r e v a l e n c e o f c o m o r b idm e n ta l a n d a d d i c t i v e d i s o r d e r s i nth e U n i t e d S t a t e s , c o m b i n e dc o m m u n i t y a n d i n s t i t u t i o n a l f i v e -
M e n t a l D i s o r d e r2 2 . 5 %
C o m o r b i d i t y 2 9 %
A l c o h o lD i s o r d e r1 3 . 5 %C o m o r b id i t y4 5 %
O th e r D r u g
D i s o r d e r
6 . 1 %
3 . 1
1 . 71 . 5
1 . 1
(Regier, Arch. Gen Psy, 1991)
19
Comorbidity in Public Sector Comorbidity in Public Sector TreatmentTreatment
National Survey on Drug Use and Health: National Findings 2004
In public sector, 49% to 70% of the clients have co-occurring mental healthand substance use disorders
20
Mental Diagnosis by Service TypeSan Francisco County 1998-2004
0
10
20
30
40
50
60
Schizop Bipolar Depress Anxiety
SAMH
N=224, recruited from MH and SA Svc Havassy, Am J Psychiatry, 161 (1), 139-
145.
21
SUD Diagnosis by Service Type
0
10
20
30
40
50
60
70
C-SAC-MH
2a. Global Concerns Key Finding #2.
Individuals with COD are among California’s most underserved.
Up to 60% of individuals receiving treatment in our public sector mental health system have COD. Most do not receive integrated care.
23
Treatment Status for COD Treatment Status for COD Respondents Respondents
In 2004 NSDUH SampleIn 2004 NSDUH SampleTreatment Status
in Prior 12 Months% of
Respondents
No Treatment 47.8
Only MH Treatment 41.4
MH andand SA Treatment 6
Only SA Treatment 5
National Survey on Drug Use and Health: National Findings 2004
24
Utilization of Mental Health ServicesUtilization of Mental Health Services
53
20
33
14
46
99
5968
50
97
0102030405060708090
100
Any MH PsychHosp
PES ADU OP
% R
ecei
ving
Ser
vice
s
SAMH
All significantly different at p < .001.
25
Percentage of Participants Percentage of Participants Who Received SA ServicesWho Received SA Services
79
59
20
45
64
31
19
48
0102030405060708090
100
Any SA Detox RT OP
% R
ecei
ving
Ser
vice
s
DTMH
***
*
Results of chi square tests. * p< .05, *** p = .000
2a. Global Concerns Key Finding #3
COD is pervasive and disabling.
Individuals with COD have more relapses, hospitalizations, depression & suicide, violence, homelessness, arrests and incarcerations, HIV, trauma and school failure.
27
Why Dual Diagnosis?Alcoholic or Substance Dependent
with Mental Health Impairment2-4 times more likely to seek
treatment than any single disorder.
(Grant, NIDA Monographs, 1997)
2a. Global Concerns Key Finding #4
Insufficient support for integrated COD treatment leads to a paucity of programs and skilled providers.
Unable to access appropriate care, individuals with COD are disproportionately served in emergency rooms, jails, foster care and among the homeless at great financial and emotional cost.
California Treatment System
Jails/Court
County DMH/ADP
Hospitals
Insured
VetAdm
University& Schools
MethadoneClinics
RecoveryHomes
Untreated
Non-Profit
Outpatient
“COD impact our Whole Treatment System”
Warning: Hospital Closures
Warning: Jail Overcrowding
16% Arrests related to MH or SA In CA some counties, up to 50%
incarcerations are meth-related.
Warning: Foster Care
70% of youth in juvenile detention, foster care or group homes abuse alcohol or drugs
60% have mental disorders.
Warning: Homelessness
COMPARE: Cost Homeless
Care $61,000 annually
Cost for Supportive Housing $16,000
2b. California’s Strengths
1. DMH & ADP Established theCo-Occurring Joint Action Council
Developed “COD State Action Plan” Screen Tool, Universal Charts, Standards
2. COD Best Practices in (16) Counties3. Multiple funding sources available.4. Effective model Peer & Family Services
COD
2b. Effective National Models
Improved Quality at Lower Cost! MHSA Supportive Housing MHSA Full-Service Partnerships California SACPA (Prop 36) AOD
Diversion Bexar County (Texas) MH Diversion Allegheny County (Penn) MH Court California AOD SBIRT (San Diego)
Just what the doctor ordered…
Decision: How do we Integrate Services?
California’s StrengthsDMH/ADP + National BP
Support ExistingCOD State Plan
TransformationThrough MHSA
DMH ADP
Change in Two Sizes
i I Little Big
Integration
Support COD State Plan
Leverage MHSA funds, where possible, to implement components of COD Plan. Screening Tool Universal Charting Training and Technical Assistance Standards and Outcomes
…Priority focus for Integrated Plans?
In a Transformed System…
Involve the Whole Community
Integrate the Whole System Treat the Whole Person
Integration Means:
To Transform a System…
The Science of Transformation
1. Change Culture: The Process of Transformation should Mirror its Goals.
2. Effective Implementation: Policy bodies must work through its intermediaries.
3. Focus on Achievable Outcomes: Measurable Progress should be rewarded
Consultants, Ken Minkoff & Chris Cline (SAMHSA)
Unique MHSA Opportunities
In a Transformed System of Integrated Care through the Mental Health Services Act…
1. Culture of Partnership: Mental Health Services should be delivered in collaboration with non-mental health partnerships; mirroring the partnership with clients and families.
2. Support Systemic Integration: Policy, Guidelines and Technical Assistance would consistently support “whatever it takes” for counties and agencies to comprehensively integrate services.
3. Measure “Whole-person” Care: The client experience of service continuity and meaningful care would be the hallmark of successful service integration.
Towards Integrated Plans…
1. Mental Health Partnerships Explore means to enhance our
Community Planning Process.
2. System-wide Integration Review Integrated Plans for Continuity
among MHSA Programs (CSS, PEI, INN, WET) and opportunities for flexible funding.
3. Client-Centered Outcomes Explore measures of “client-centered”
satisfaction and “continuity of care.” …Forward to Integrated Plan Discussion
3. Recommendation
“The MHSOAC should promote Co-occurring Disorders Competency
as a core value in implementation of the
MHSA and this value should be reflected in the Commission’s Annual
Strategic Plan.”
Analysis
“By adopting co-occurring disorders competency as a core-value, the MHSOAC provides policy direction which facilitates the achievement of 10 key goals necessary to improve the treatment of co-occurring disorders, as well as, transform the mental health system in California.”
Transformative Goals for the Mental Health Services Act
Goal 1: Create a Culturally Competent Integrated System of CareGoal 2: Establish Systemic PartnershipsGoal 3: Encourage DMH and ADP CollaborationGoal 4: Provide Ample Training and Technical AssistanceGoal 5: Close Gaps in the Continuum of CareGoal 6: Expand Peer-based Wellness & Recovery ServicesGoal 7: Empower Families to Enhance RecoveryGoal 8: Effectively Treat TraumaGoal 9: Use Outcomes to Measure ProgressGoal 10: Provide Incentives to Promote Transformation
In a Co-Occurring Disorders Competent System…
In a Co-occurring Disorders Competent System…1. Integrated Care: Mental Health Care in California will
be provided through an integrated continuum of care.
2. Partnerships: Mental Health Care in California will reflect a public health perspective, which results in the development of collaborative partnerships.
3. Collaboration: DMH & ADP will support COJAC’s state plan.
4. Training: MHSA Training & Technical assistance will support ongoing workforce development and behavioral health competency.
5. Comprehensive Continuum: Services for mental illness and substance abuse will be comprehensive and promote seamless transition in and out of emergency services.
In a Co-occurring Disorders Competent System…6. Peer-Based Recovery: Peers will be broadly involved
in the continuum of care and provide peer-based wellness and recovery services.
7. Strengthen Families: Families will be engaged and assisted to support and sustain recovery.
8. Trauma Awareness: Competency to treat trauma will be promoted and valued in MHSA programs.
9. Measure Progress: Use evidence & appropriate outcomes.
10. Incentive Transformation: Encourage growth of the mental health system towards greater integration and co-occurring competency.
Next Steps for COD
1. Recommendation Approved 11/08
2. Services Committee to prioritize
Pating’s recommendations: Implement Screen Tool COD Standards of Care Offender-based Treatment
Status of Co-occurring Disorders Collaboration in
California
Current Status: COD
1. Minkoff “Change Agents” 2. COJAC Screening Tool3. Administrative Office of Courts
Inquiry4. COD Prevention and Early
Intervention
Look Ahead: COD
Integrated Primary Care Initiative Universal Chart MHSA Integrated Plans
MHSA Prevention and Early Intervention Projects Addressing Co-Occurring Disorders
David Pating, MDOctober 2009
45 PEI Plans Approved = $320,699,429 October 2009 Commission Meeting will include:
Sacramento PEI Plan = $1,600,000 Ventura PEI Plan = $5,250,583 Will total 47 PEI Plans = $327,550,012
22 Training, Technical Assistance & Capacity Building (Info. No.: 08-37) = $8,7456,900
20 Annual Updates = $84,786,707 2 Innovation Plan = $479,549
Approved PEI Funds to Date
Examples MHSA PEI Projects Addressing Co-Occurring Disorders
San Diego County:
In 2002 they adopted the Comprehensive, Continuous, Integrated System of Care (CCISC) model to improve services for persons with co-occurring disorders. The model outlines 4 quadrants (broad parameters) of responsibility of Alcohol and Drug Services (ADS) and Mental Health (MH) programs for persons with co-occurring disorders
Quadrant III are persons identified (respectively) with high substance abuse issues/treatment issues & low MH issues/treatment needs and are high-risk for SMI
Examples MHSA PEI Projects Addressing Co-Occurring Disorders
San Diego County: PEI Project Goals
Screening, brief intervention and referrals for 1800 people identified as Quadrant III
Training for Staff and Law Enforcement Linkages to Providers, rehabilitation programs,
detox, self-help groups, sober living homes, counseling, legal services etc.
Collaboration with TAY and Older Adult programs, Teen Centers, Senior Centers, health care providers, community clinics and expanded collaboration with ADS providers/resources
Annual outcome evaluation
Examples MHSA PEI Projects Addressing Co-Occurring Disorders
San Diego County:
Embedded Mental health and Substance Abuse staff served in San Diego County Psychiatric Hospital Crisis Recover Unit – 6,000 adults (25-59)– 1,000 TAY (18-24)– >300 Older Adults (60+)
These individuals made almost 16,000 visits in FY2006-07
Examples MHSA PEI Projects Addressing Co-Occurring Disorders
Riverside County:
Seeking Safety Program simultaneously helps people with a history of trauma and substance abuse issues
Guiding Good Choices Program is a prevention program
for the Native America (NA) Community 9-14 years old. “With the historical trauma in NA communities substance abuse is inextricably linked with depression, Bi-Polar Disorder and PTSD.” – Riverside County PEI plan page 143
Riverside County PEI Plan has resources/collaboration or referrals available in virtually all of their programs
Examples MHSA PEI Projects Addressing Co-Occurring Disorders
City of Berkeley – coordinated system for screening for post-partum depression and peri-natal alcohol and other drug use
San Francisco – within Trauma and Recovery Services Project they are offering a comprehensive, culturally competent, co-occurring capable services for youth and families affected by violence and trauma
Fresno – had a co-occurring specific focus group and has a PEI project designed to address the trauma experienced by the children of substance abusing or gambling addicted fathers
Examples MHSA PEI Projects Addressing Co-Occurring Disorders
Marin County: Youth 15-21 have the highest prevalence (over 60%) of co-
occurring substance abuse and mental health disorders Marin County integrating services for people with Co-
Occurring disorders in PEI Programs: Older Adults, Home Delivered Meals PEI Program Suicide Prevention Project Children and Youth PEI (co-occurring assessment with parents) Increased collaboration with Student Assistance Program and
Department of Education TAY Prevention and Early Intervention Project Primary Care Integration Project
Examples MHSA PEI Projects Addressing Co-Occurring Disorders
PEARLS: Program to Encourage Active And Rewarding Lives for
Seniors Evidenced Based Practice Reviewed by the Nations Registry of Evidence-based
Programs and Practices of the Substance Abuse and Mental Health Services Administration
A few Counties who are implementing PEARLS Imperial - San Diego Los Angeles - San Joaquin Merced - Riverside
Examples MHSA PEI Projects Addressing Co-Occurring Disorders
Global MHSA PEI REVIEW
A review of 28 of the 45 approved PEI plans found that 75% of the plans included some attention to or consideration for people with co-occurring disorders
The Future of Co-Occurring Disorders
“The MHSOAC [and its partners] should support the transformation of mental health care by immediately investing in the integrated treatment of co-occurring disorders—to act both politically and financially.
The long-term dividends from investment in Co-occurring Disorders will reap major financial savings and improve overall mental health and social welfare far beyond meeting the challenge of co-occurring mental illness and substance abuse.”
-COD report, p 24
Acknowledgements The MHSOAC Co-occurring Disorders (COD) Workgroup would like to thank the members of
our predecessor COD Workgroup for their efforts in bringing this issue to the attention of Californians. The 2007 COD Workgroup included: Gary Jaeger, Judge Steven Manley, Rod Shaner, and Rusty Selix.
This report is the culmination of over eight months of work on the part of the 2008 COD Workgroup. The 2008 Workgroup was comprised of: Workgroup Chair and MHSOAC Commissioner David Pating, Workgroup Co-Chair and Commissioner Beth Gould, Commissioner Larry Poaster, Commissioner Darlene Prettyman, Maureen Bauman, Delphine Brody, Nick Damian, Pia Escudero, Mary Hale, Patricia Harris, Joan Hirose, Sandra Marley, Alice Gleghorn, Rusty Selix, John Sheehe, Marvin Southard, Cheryl Trenwith, Henry van Oudheusden, and Dede Ranahan.
We also thank our many presenters who took the time to travel to inform the Workgroup and the public about the latest issues in COD policy. The 2008 presenters to the COD Workgroup included: Delphine Brody, Alice Gleghorn, Kathy Jett, Gary Jaeger, Patricia Johnson, Sheree Kruckenberg, Stephen Mayberg, Dede Ranahan, Tom Renfree, Rusty Selix, Vicki Smith, Marvin Southard, Cheryl Trenwith, Alice Trujillo, and Renee Zito.
The MHSOAC COD Workgroup would like to recognize the leadership and tenacity of David Pating, principal author, to bring this report to completion. His experience, dedication and boundless energy inspired us to complete this report.
Thanks to Stuart Buttlaire, Richard Conklin and Sheri Whitt for their consultation during the writing of this report.
Special thanks to MHSOAC staffers Matt Lieberman and Deborah Lee for their contributions to writing and editing this report. Thank you to Dede Ranahan and Dan Souza for writing contributions.
MHSOAC COD Workgroup Co-Chairs, David Pating and Beth Gould
