Introduction to the Dual Diagnosis Capable Mental Health Treatment (DDCMHT) Framework Detroit Wayne Mental Health Authority Systems Transformation Project Provider Partners: Tinetra Burns MS, LSST, CADC-M (Team Mental Health) Maeola Dacus LMSW, ACSW (Detroit Central City) Dr. Beth Rutkowski, LP, CAADC (Hegira Programs)

Introduction Mental health treatment providers are continually challenged to improve service capability. Over the past 15 years, there has been an increased awareness of the common presentation of persons with co-occurring (mental health and substance use) disorders.

Why Use Change Processes? Improve client outcomes Increase access to effective treatment Engage staff Save time Transform organizations

Introduction (continued) Research suggests that sequential treatment (treating one disorder first, then the other) and purely parallel treatment (treatment for both disorders provided by separate clinicians or teams who do not coordinate services) are not as effective as integrated treatment (Drake, O’Neal & Wallach, 2008).

Introduction (continued) National and state initiatives related to co-occurring disorders have been significant, stimulating considerable interest in providing better services for people with these challenges. Although an understanding has been established, mental health providers may lack guidance on how to improve services.

Introduction (continued) Specific evidence-based treatment modalities have been developed, including Integrated Dual Disorders Treatment (IDDT; Mueser et al., 2003; SAMHSA, 2003). However, providers continue to identify the need for practical guidance to develop and implement co-occurring services.

Introduction (continued) The DDCMHT index was first developed in 2004, as a parallel instrument to the DDCAT (Dual Diagnosis Capability in Addictions Treatment) Index developed in 2003. Both are based on the American Society of Addictions Medicine (ASAM) taxonomy of dual diagnosis capability for service programs.

Introduction (continued) The DDCMHT, which will be described more later in this presentation, guides programs and system authorities in assessing and developing dual diagnosis capability of mental health treatment (McGovern, Matzkin & Girard, 2007). Dartmouth’s Practice Demo Videos on Integrated Treatment for Co-Occurring Disorders provides useful resources including an overview, stages of change and treatment, engagement stage interventions, and assessment.

What is being assessed? The Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index, and the Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index establish benchmarks for providing evidence-based treatment services to individuals with co-occurring disorders. These indices ask questions about seven dimensions within the three primary areas of Policy, Clinical Practice, and Workforce. 9

Policy The 1st dimension is Program Structure, asking the question: “Do your overall program structure and policies help or inhibit providing services for individuals with co-occurring disorders?” To answer this question, the following is considered: the program’s mission statement; the organizational certification and licensure; coordination and collaboration with mental and/or addiction health services; financial incentives. 10

Policy The 2nd dimension is Program Milieu, asking the question: “Are the staff and physical environment welcoming and receptive to individuals with co-occurring disorders?” To answer this question, the following is considered: the program’s expectation of welcome to treatment for both disorders; the program’s display and distribution of literature and patient educational materials. 11

Clinical Practice The 3rd dimension is Assessment, asking the question: “How does your staff make distinctions between symptoms, substance-induced disorders, or actual psychiatric disorders that may need treatment?” To answer this question, the following is considered: routine screening methods and assessment for both types of disorders; diagnoses made and documented; recorded history of both types of disorders; program acceptance based on acuity, severity & persistence of the disabilities; whether stage-wise assessment is present. 12

Clinical Practice The 4th dimension is Treatment, asking the question: “How do your clinical assessment and treatment procedures and protocols rate in relation to co-occurring disorder assessment and treatment?” To answer this question, the following is considered: treatment planning; assessment & monitoring of interactivity of both disorders; procedures for emergencies & crisis management; stage-wise treatment; policies and procedures for medication evaluation, management, monitoring, & compliance; specialized interventions, education & support for the client and their family; use of peer supports/groups for planning or during treatment. 13

Clinical Practice The 5th dimension is Continuity of Care, asking the question: “How does your program handle continuing care and monitoring for individuals with co-occurring disorders?” To answer this question, the following is considered: integration of co-occurring disorders in discharge planning process; the capacity to maintain treatment continuity; a focus on ongoing recovery issues for both disorders; specialized interventions to facilitate use of community- based peer; support groups during discharge planning; sufficient supply and compliance plan for medications. 14

Workforce The 6th dimension is Staffing, asking the question: “Do any staff members have expertise in assessing and treating individuals with co-occurring disorders?” To answer this question, the following is considered: presence of a psychiatrist or other prescriber of psychotropic medications; on-site clinical staff members with mental health licensure (doctoral or masters level), competency or substantive experience; access to mental health clinical supervision or consultation; case review, staffing or utilization review procedures emphasizing and supporting co-occurring disorder treatment; peer/alumni support availability with co-occurring disorders. 15

Workforce The 7th dimension is Training, asking the question: “Are staff members adequately trained and supported for the assessment and treatment of individuals with co-occurring disorders?” To answer this question, the following is considered: whether all staff members have basic training in attitudes, prevalence, common signs and symptoms, detection and triage for co-occurring disorders; whether clinical staff members have advanced specialized training in integrated psychosocial or pharmacological treatment of persons with co-occurring disorders. 16

How is the measure scored? Each of the 35 program elements of the DDCAT/DDCMHT is rated on a scale of 1-5. By considering the total scores across dimensions, DDCAT & DDCMHT can help categorize a treatment program into 1 of 3 primary categories: Mental Health or Addiction Only Services (MHOS or AOS), if less than 80% of scores are 3s or greater Dual Diagnosis Capable (DDC), if at least 80% of scores are 3 + Dual Diagnosis Enhanced (DDE), if at least 80% of scores are 5 + Scores of 2 and 4 are reflective of the levels between the standards established at the 1=Alcohol or Mental Health Only, 3=Dual Diagnosis Capable, and 5=Dual Diagnosis Enhanced levels. 17

What do those categories mean? Addiction Only Services (AOS) or Mental Health Only Services (MHOS) designate a program that is focused on providing services to persons with only mental health, or only substance use disorders. Dual Diagnosis Capable (DDC) indicates a program that is capable of providing services to some individuals with co-occurring substance use and mental health disorders, but has greater capacity to serve individuals with whatever the primary designation of the program is. Dual Diagnosis Enhanced (DDE) designates a program that is capable of providing services to any individual with co-occurring substance use and mental health disorders, and the program can address both types of disorders fully and equally. Programs at the DDE level are often indistinguishable as either an addiction or mental health treatment program. 18

DDCAT/DDCMHT Methodology What To Expect at a Site Review When Rating a Program’s Co-occurring Capability Site visit – Scheduled in advance with agency director or designee. Site visit may take a full or half day, depending upon the number of programs within the agency being assessed.

DDCAT/DDCMHT Methodology Ideally a team of two assessors but may be more conducting the review. Team consist of objective reviewers who score independently but generally come to consensus on the basis for scoring. Utilizes objective ratings, however, understanding the definition and item response coding for each element is critical.

DDCAT/DDCMHT Data Sources Observations of milieu and physical settings Tour of Program/Facility Focused, open-ended interviews with staff, e.g., agency leadership (administrative and supervisory), staff clinicians, medical prescribers, support personnel, and consumers, etc. Review of open and closed chart documentation (screenings, assessments, med reviews, progress notes, team meeting logs, etc.)

Sources of Data (continued) Policy and procedure manuals, brochures, patient/program schedules, patient/family handouts, and other relevant forms/materials Observation of clinical treatment process (group meetings, team meetings and supervision sessions, etc.) Staff training records Information obtained from multiple sources

The Site Review Works Best As: A collaborative effort Positive and affirming, rather than punitive and judgmental Emphasizing program strengths Identifying barriers/areas for growth/change Assessing organizational stage/readiness to change Leading to themes/strategies to enhance overall program and services

The Site Review Visit Includes: Initial and exit meetings Verbal feedback during the site visit Follow-up with written integrative summary report following the site visit Results from the DDCAT/DDCMHT review can be used as baseline data and a measure for improvement of services over time. Annual reviews will be conducted and technical assistance provided as needed.

Self Ratings Data shows that self assessors generally rate themselves higher in all dimensions and view themselves more co-occurring capable than they are, as opposed to external objective assessors. Programs that desire to self-assess are encouraged to use their quality assurance team or staff from another program other than the one being assessed. This helps minimize biases since these are usually more familiar with the process of record review, and are encouraged to base scores on factual evidence rather than assumptions or biases.

Practical Improvements I. Program Structure Shift in mission statement from focus on one disorder only to co-occurring disorders Clarification of myths about billing or service constraints Use of a collaborative model versus a consultation model Design policies to support integrated practice and service documentation across various funding and licensing bodies Provide an equivalent focus on both co-occurring conditions Seek secondary or additional licensure to provide the other service

Practical Improvements II. Program Milieu Provide access to brochures that describe program capability to address more than one presenting concern Address questions or raise awareness about co-occurring concepts in orientation sessions Create an atmosphere that welcomes individuals Create a milieu or cultural shift to an equivalent focus on substance abuse and mental health disorders Have readily available materials on the common occurrence of co-occurring disorders and process of recovery

Practical Improvements III. Clinical Process: Assessment Offer both a mental health and substance use assessment to individuals identified via screening or history Utilize standardized screening measures that assess for mental health and substance use problems or are sensitive to identifying mental health and substance use problems Utilize a systematic substance use and mental health assessment for all clients

Practical Improvements IV. Clinical Process: Treatment Mental health and substance abuse problems are identified or targeted by at least generic treatment interventions, and monitored for treatment response Routinely assess motivational stage during treatment and consider modifications of treatments accordingly Utilize individual family sessions or multi-family groups that often present comorbid psychiatric problems as a complicating factor in recovery Presence of a documented and equivalent focus on treatment planning for both co-occurring disorders

Practical Improvements V. Continuity of Care Implement a deliberate plan post-discharge that considers the influence of the co-occurring disorders on one another Make efforts to match the individual with community support groups, with a plan to foster the connection Place an equivalent focus on discharge planning for both substance use and psychiatric disorders Treatment providers and interventions, medications and dose, recovery supports and relapse risks for both disorders are well described and documented

Practical Improvements VI. Staffing Request medical provider attend clinical team meetings Increase the number of both mental health and substance counselors and educated, trained clinicians who can deliver the most basic and generic treatment Match persons with specific co-occurring disorders with peer role models Consistently and systematically review client progress related to substance abuse and mental health problems

Practical Improvements VI. Staffing Make a more definitive practice of hiring and staffing the program with personnel who can provide co-occurring disorder assessments and treatment Capitalize on a network of community volunteers, alumni and others to strategically connect individuals diagnosed with COD with others

Practical Improvements VII. Training Make commitments to have the majority of the staff trained in basic issues pertaining to co-occurring disorders: attitudes, prevalence, screening, triage, and brief interventions Organize a training strategy to track and direct staff needs for training and document trainings received Make a substantial investment in creating a “no wrong door” experience for individuals at the level of the program and clinician

References Center for Substance Abuse Treatment. Definitions and Terms Relating to Co-Occurring Disorders. COCE Overview Paper 1. DHHS Publication No. (SMA) 06-4163 Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2006. Implementing Change in Substance Abuse Treatment Programs. Technical Assistance Publication Series 31. HHS Publication No. (SMA) 09-4377. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009. Substance Abuse and Mental Health Services Administration, Dual Diagnosis Capability in Addiction Treatment Toolkit Version 4.0. HHS Publication No. SMA-xx-xxxx, Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. http://www.samhsa.gov/co-occurring/DDCAT/index.html http://www.samhsa.gov/co-occurring/DDCAT/references-and- downloads/downloads.html