Rationale 100% of consumers seen at intake present with a major mental illness SchizophreniaSchizophrenia Bi-polar DisorderBi-polar Disorder Affective DisordersAffective Disorders 90% of consumers at intake present with a co-occurring substance abuse disorder. Crack Alcohol Marijuana Polysubstance Intake staff needed further training in order to address the needs of this priority populations. Information gathered by the intake department will inform the agency about the prevalence and incidence of dual disorder in the referral pool and hence will impact agency wide service decisions.
Goal My Goal: Improve the ability of the Intake Team at Community Connections to accurately identify, assess and categorize new Dually Diagnosed (DD) clients.
ImplementationINTAKETRAININGMODULE SCREENING:InterviewMSEMIDASASSESSMENT:Longitudinalintegrated assessment of co-occurringdisordersTREATMENT&RESOURCES:APRA
Screening 1.Interview Framework: 95% of our consumers have co-occurring disorders. 95% of our consumers have co-occurring disorders. Know your own bias. Know your own bias. Don’t forget to ask questions if you want the answers! Don’t forget to ask questions if you want the answers! Recognize what you see. Recognize what you see. 2.MIDAS () 2.MIDAS (Minkoff, K. 2001) A self-report tool A self-report tool Refers to previous six months Refers to previous six months Any “yes” answer could indicate a problem with drugs/alcohol Any “yes” answer could indicate a problem with drugs/alcohol Some differentiation between abuse/dependence Some differentiation between abuse/dependence Some specific internal decision rules Some specific internal decision rules Follow up with assessment Follow up with assessment 3.Mental Status Exam 3.Mental Status Exam The MSE is the basis for understanding the client's presentation and beginning to conceptualize their functioning into a diagnosis.
Screening - The MIDAS Self Report about drug/alcohol problems Self assessment Doctor’s assessment Family’s assessment Related legal problems Complications of medical problems Interaction of drug & mental health issues Drugs to relieve MH problems Drugs worsen MH problems Problem with med compliance due to drugs Feelings of: Symptoms of withdrawal Guilt due to drug use Being out of control due to drug use Belief that one is an addict or alcoholic Self report of: Problem with provider, school, work Increase in ER visits Detox Related Psychiatric hospitalization Attendance at AA/NA Other SA Treatment
Screening - Mental Status Exam Orientation Rapport and Attitude Appearance Mood Affect Speech Thought Process Thought Content Dangerousness Hallucinations Insight Judgment Judgment Behavior Cognition Memory (please indicate good, fair, or impaired for each) Psychomotor Activity Sleep Appetite Substance Use General Psychiatric Condition
Assessment Recognizing, conceptualizing and categorizing substance abuse and mental health symptoms are key components of the intake process… Issues in assessing co-existing disorders Key Questions Sub-groups of people with co-existing disorders Stages of Change Phases of Recovery Stages of Treatment
Issues in Assessment* Assessment Principles Relationship based Relationship based Integrated Integrated Longitudinal Longitudinal Strengths Based Strengths Based Comprehensive Comprehensive Continuous Continuous Systematic Systematic * CCISC from Ken Minkoff, MD Assessment Content Strengths Symptoms Successful Treatment Stage of Change, Treatment Supports Spiritual and Cultural Framework Skills Somatic Issues Significant Problems or Contingencies
Key Questions in Assessment Substance Abuse ? When did you start using drugs? When did you start using drugs? What drugs have you used in your life? What is your drug of choice? What drugs have you used in your life? What is your drug of choice? Are you experiencing withdraws or other medical problems? Are you experiencing withdraws or other medical problems? Tell me about your treatment history… Tell me about your treatment history… How much clean/sober time do you have? How much clean/sober time do you have? How easy was it for you to access services How easy was it for you to access services Mental Health ? What is the presenting problem? What is the presenting problem? Are you in crisis – SI/HI? Are you in crisis – SI/HI? What symptoms are you experiencing? What symptoms are you experiencing? What medications are you taking and who is your doctor? What medications are you taking and who is your doctor? What is your treatment/hospitalization history? What is your treatment/hospitalization history? What services are you looking for? What services are you looking for?
Assessing Subgroups* SUB-GROUPS OF PEOPLE WITH COEXISTING DISORDERS: Patients with “Dual Diagnosis” – combined psychiatric and substance abuse problems – who are eligible for services fall into four major Quadrants. CCiSC 2001 *Minkoff, K CCiSC 2001 PSYCH. HIGH SUBSTANCE HIGH Serious & Persistent Mental Illness with Substance Dependence QUADRANT IV PSYCH. LOW SUBSTANCE HIGH Psychiatrically Complicated Substance Dependence QUADRANT III PSYCH. HIGH SUBSTANCE LOW Serious & Persistent Mental Illness with Substance Abuse QUADRANT II PSYCH. LOW SUBSTANCE LOW Mild Psychopathology with Substance Abuse QUADRANT I
Assessing Stage of Change* In order to engage a client effectively at intake it is critical to meet the client where they are with their recovery/treatment: Pre-contemplation Contemplation Preparation Action Evaluation, CCISC 2001 *Minkoff, K & Cline, C., CCISC 2001
Assessing Phase of Recovery* Both substance dependence and mental illness are disorders which can be understood using a disease and recovery model with parallel phases of recovery. Recommendations made at intake about the current phase of recovery has implications for engagement and prioritizing treatment needs. PHASE 1: Stabilization - Stabilization of active substance use or acute psychiatric symptoms PHASE 2: Engagement/Motivational Enhancement - Engagement in treatment - Contemplation, Preparation, Persuasion PHASE 3: Prolonged Stabilization - Active treatment, Maintenance, Relapse Prevention PHASE 4: Recovery & Rehabilitation - Continued sobriety and stability - One year – ongoing * CCiSC 2001 * Minkoff, K CCiSC 2001
Assessing Stage of Treatment* Engagement - Lack of working alliance Early Persuasion - Working alliance with some discussion about SA and MI issues Late Persuasion - Engaged and there is a reduction in use for 1 month Early Active Treatment - Reduced use, working towards abstinence and improved well being. Late Active Treatment - Acknowledges SA as a problems, achieves abstinence and manages symptoms < 6 months. symptoms < 6 months. Relapse Prevention - Acknowledges SA as a problems, achieves abstinence and manages symptoms for at least 6 months. symptoms for at least 6 months. *Drake, R.E., Dartmouth-New Hampshire Psychiatric Research Center
Recommendations & Resources for Treatment Stage specific treatment recommendations: General treatment Issues for DD population –Stabilization of acute symptoms followed by housing, establishing a working alliance, counseling and psycho-education needs, family issues, practical help and benefits, medication coordination. Substance Abuse resources APRA Mental Health resources CPEP Community Support Agencies
Stage Specific Treatment Recommendations* Stabilization Hospitalization, Detox, Incarceration, Crisis Houses, ACT Teams, Civil Commitment Engagement Focus - Wet Housing Outreach, Support in community, What client wants, Initial exploration, Without contingency, Facilitate access, provide practical assistance Persuasion Focus - Damp Housing, Expect slips, Cognitive Behavioral, Focused, specific info, Involve family in tx, Improve standard of living, Help with cravings, detox. Active Treatment Focus - Dry Housing, Expect slips, Cognitive Behavioral, Focused, specific info, Involve family in tx, Improve standard of living, Help with cravings, detox family in tx, Improve standard of living, Help with cravings, detox Relapse Prevention More independent, Increase self-efficacy and self advocacy, Self-help, RP plans, Health, well-being, Repair burned bridges, Teach negotiation skills, recognition of early warning. *Mueser, K.T. and Drake, R.E.
Substance Abuse Resources APRA: Addiction Prevention and Recovery Administration Administration Contact and Referral Information: 825 North Capitol Street, NE Washington, DC Telephone: (202) Hours of Operation: 8:30 am - 5:30 pm 24 Hour Hotline: 1(888) 7WE-HELP A special thank you to Bonita Bantom, LICSW for taking the time to come to Community Connections to train us on services offered by APRA and the referral process.
APRA APRA is DC’s single state agency on substance abuse prevention and treatment. Under the Department of Health, it is the primary provider of substance abuse services for insured and uninsured DC residents. APRA conceptualizes Substance Abuse disorders as “biopsychosocial” in nature and gears it’s services to meet the needs of the whole person. APRA’s role in DC includes: Planning & implementing the City-Wide Comp Substance Abuse Strategy. Planning & implementing the City-Wide Comp Substance Abuse Strategy. Managing community based Primary & Secondary prevention programs. Managing community based Primary & Secondary prevention programs. Providing a comprehensive array of treatment services. Providing a comprehensive array of treatment services. Administers standard of care certification requirement for providers. Administers standard of care certification requirement for providers.
APRA: Innovative Treatment Initiatives: Aftercare Assessments and Referrals Certification Detoxification Services Drug Treatment Choice Program Employment Services (APEX) Outpatient Services Prevention and Youth Treatment Services Primary Medical Care Project Orion Residential Services Special Population Services Special Services for Persons with HIV/AIDS Special Services for Latinos Special Services for LBGT Community Special Services for Mental Health Special Services for Seniors Special Services for Women with Children Spiritual Faith Groups 12-Step Meeting Information
Mental Health Resources Department of Mental Health (DMH)* Services: Adult Forensics Child & Family Therapy Comprehensive Psychiatric Emergency Program Educational Services Educational Services Homeless Services Individual & Group Therapy Infants, Toddlers, & Parents Multicultural Services Organizational Development Mental Health Rehabilitation Services *
MHRS Services Crisis & Emergency 24 Hour Access Helpline ( WE-HELP) Crisis and Emergency 24 Hour Access Helpline ( WE-HELP) Crisis and Emergency CPEP CPEP Crisis Houses – Jordan House and Crossing Place Crisis Houses – Jordan House and Crossing Place Community Support 11 Core Services Agencies – Cal AHL for referral. 11 Core Services Agencies – Cal AHL for referral. Day Services/Intensive Day Services Life Stride - (202) Life Stride - (202) McClendon Center - (202) McClendon Center - (202) PSI - (202) PSI - (202) Community Based Intervention (CBI) Youth Villages- (865) Youth Villages- (865) Home First Care -(202) Home First Care -(202) Beyond Behaviors -(703) Beyond Behaviors -(703) Family Preservation Services - (202) Family Preservation Services - (202) Assertive Community Treatment (ACT) DCCSA - (202) DCCSA - (202) Pathways to Housing -(202) Pathways to Housing -(202) Psychotherapeutic Outreach Services -(202) Psychotherapeutic Outreach Services -(202)
Community Connections Community Connections is a Core Service Agency located in SE Washington DC. It employs approximately 300 staff members and serves 2000 consumers. Integrated intakes are completed daily by licensed clinicians. Consumers are assigned to one of the following specialty teams Trauma Trauma HIV/Wellness HIV/Wellness Recovery Recovery Forensic Forensic Dual Disorder Dual Disorder Children/Adolescents Children/Adolescents Additional Services: Psychiatric Clinic Psychiatric Clinic Day Services and Community Support Groups Day Services and Community Support Groups Psychotherapy Clinic Psychotherapy Clinic Supported Employment Supported Employment Benefits Specialist Benefits Specialist Multiple Research Projects
Outcomes 1. 6 intake staff trained on integrated assessment of dual disorders integrated assessment completed since September 1, Overall increase in awareness across agency about DD issues % more accurate case assignment. 5. Improvement in frequency and timeliness of referrals to detox and other APRA services.
Community Connections Intake Department Roshni Chatterjee, LPC Director of Intake / Suzanne Bechard, LICSW Intake Coordinator for Children and Adolescents / Sarah Ahmed, LICSW Intake clinician and Psychotherapist Caroline Quezada, LICSW Intake clinician Kirsten Winters, LICSW Intake clinician and Psychotherapist Victoria Sherk HIV and Wellness program