1. INTEGRATION OF CARE FOR CO-OCCURRING DISORDERS BEGINS AT INTAKE Roshni Chatterjee, LPC Director of Intake Community Connections Washington DC

2. Integration  Rationale  Goal  Implementation  Outcomes

3. 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.

4. Goal My Goal: Improve the ability of the Intake Team at Community Connections to accurately identify, assess and categorize new Dually Diagnosed (DD) clients.

5. ImplementationINTAKETRAININGMODULE SCREENING:InterviewMSEMIDASASSESSMENT:Longitudinalintegrated assessment of co-occurringdisordersTREATMENT&RESOURCES:APRA

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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?

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. Substance Abuse Resources APRA: Addiction Prevention and Recovery Administration Administration Contact and Referral Information: 825 North Capitol Street, NE Washington, DC 20002 Telephone: (202) 442-9152 Hours of Operation: 8:30 am - 5:30 pm http://app.doh.dc.gov/about/index_apr.shtm 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.

19. 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.

20. 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

21. 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 * http://dmh.dc.gov/dmh/site/default.asp

22. MHRS Services  Crisis & Emergency 24 Hour Access Helpline (1-888-7WE-HELP) Crisis and Emergency 24 Hour Access Helpline (1-888-7WE-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) 635-2320 Life Stride - (202) 635-2320 McClendon Center - (202) 737-6191 McClendon Center - (202) 737-6191 PSI - (202) 547-3870 PSI - (202) 547-3870  Community Based Intervention (CBI) Youth Villages- (865) 560-2548 Youth Villages- (865) 560-2548 Home First Care -(202) 737-2554 Home First Care -(202) 737-2554 Beyond Behaviors -(703) 658-9300 Beyond Behaviors -(703) 658-9300 Family Preservation Services - (202) 543-0387 Family Preservation Services - (202) 543-0387  Assertive Community Treatment (ACT) DCCSA - (202) 671-4010 DCCSA - (202) 671-4010 Pathways to Housing -(202) 393-5611 Pathways to Housing -(202) 393-5611 Psychotherapeutic Outreach Services -(202) 588-9540 Psychotherapeutic Outreach Services -(202) 588-9540

23. 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

24. Outcomes 1. 6 intake staff trained on integrated assessment of dual disorders. 2. 300 integrated assessment completed since September 1, 2006. 3. Overall increase in awareness across agency about DD issues. 4. 100% more accurate case assignment. 5. Improvement in frequency and timeliness of referrals to detox and other APRA services.

25. Community Connections Intake Department Roshni Chatterjee, LPC Director of Intake 202 608 4742/ 202 546 1412 RChatterjee@ccdc1.org Suzanne Bechard, LICSW Intake Coordinator for Children and Adolescents 202 548 4890 /202 546 1512 SBechard@ccdc1.org Sarah Ahmed, LICSW Intake clinician and Psychotherapist 202 546 1512 SAhmed@ccdc1.org Caroline Quezada, LICSW Intake clinician 202 546 1512 CQuezada@ccdc1.org Kirsten Winters, LICSW Intake clinician and Psychotherapist 202 546 1512 KWinters@ccdc1.org Victoria Sherk HIV and Wellness program 202 546 1512 VSherk@ccdc1.org