1. Comprehensive, Continuous, Integrated, Systems of Care Model
An Introduction to The CCISC Model
Anne Arundel County
Co-Occurring Change Agent Group

2. Introduction The CCISC Model Is a Model of Best Practice
(Comprehensive Continuous Integrated Systems of Care)
Is a Model of Best Practice
Principles Of Treatment
2001 version was based on work of a consensus panel that led to a SAMSHA report in 1998 entitled: “Individuals with Co-occurring disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies, and Training Curricula” (Minkoff, 1998)

3. CCISC Model
Developed by Kenneth Minkoff, MD, Clinical Assistant Professor of Psychiatry, Harvard Medical School

4. CCISC Model
For the purpose of improving treatment capacity for individuals with co-occurring psychiatric and substance disorders.
Key words are “treatment capacity” Co-occurring clients have historically been caught in gaps of treatment. We frequently lament the fact that they “fall through the cracks”
The beginning of this model was in when Kenneth Minkoff chaired a consensus panel to establish guidelines for standards of care for indiciduals with co-occurring disorders for managed care. This was a huge undertaking and included input from virtually all professionals in the U.S. who were making strides in treating this population. The list of contributors included David Mee Lee, Kathleen Sciacca, Maryland’s own Fred Osher, Prochaska & DiClemente and numerous others

5. CCISC Model
The latest version, complete with a “Train the Trainers Curriculum” was developed in collaboration with Christie A. Cline, MD, MBA, formerly of the New Mexico Department of Health
Dr. Cline served in several capacities including Medical Director
She was a clear and constructive voice at the SAMHSA Consensus hearings in

6. Basic Characteristics
System Level Change
System level change ix accomplished by implementing the model at the program level, the clinical practice level, and the clinician competency level
Program Level = No wrong door
Clinical practice level = learn and apply best practices – for example, psych meds and relapse
Clinician competency level – training, motivational enhancement

7. Basic Characteristics
Efficient Use of Existing Resources
Does not require additional resources – other than planning, technical assistance, and training.

8. Basic Characteristics
Incorporation of Best Practices
CCISC is recognized by SAMHSA as a best practice and it utilizes evidence based on research and clinical consensus
1. Welcoming
Motivational Enhancement

9. Welcoming!

10. Stages of Change Prochaska & DiClemente
The Stages of Change model is key to understanding the process of recovery

11. Motivational Enhancement
Express Empathy
Develop Discrepancy
Avoid Argumentation
Roll with Resistance
Support Self Efficacy

12. Basic Characteristics
Integrated
Treatment Philosophy
Integrates the principles and perspective of both mental health and substance abuse professionals and utilizes a common language
Parallel treatment
Sequential Treatment

13. Principles of CCISC Model
# 1 The co-occurrence of A Substance Abuse Disorder and Mental Illness is an expectation, not an exception.
Research tells us this.
Experience tells us this
Clients may try to hide it based on their past experience
Treatment programs must be proactive in fully diagnosing clients

14. Principle # 2
All Co-occurring Clients are not the same. Treatment must be individualized.
One of the ways it must be individualized is locus of care. Where should the client be treat

15. Appropriate Level of Care
Addiction or Mental Health Only
Dual Diagnosis Capable
Dual Diagnosis Enhanced

16. Four Quadrant Model misa Minor Mental Illness Mild or no Sub Abuse
miSD
Major Sub Dependence
MIsa
Major Mental Illness
Mild Sub Abuse
MISA

17. Locus of Care According to Four Quadrant Model

18. Principle # 3
Successful Treatment is based on empathic, hopeful, integrated and continuing relationships
Welcoming and Motivational Enhancement are key to engaging and maintaining client in treatment
Clients often present as train wrecks – tough to be hopeful
Different disciplines are better at empathetically detaching from some presentations than others

19. Principle # 4
Case Management and clinical care must be properly balanced with:
empathic detachment,
opportunities for empowerment and choice,
contracting,
contingent learning.
Empathic detachment - usually SA professionals find it easier to empathetically detach from SA related behaviors and MH professionals from MH issues
Strength based treatment is the best practice and strength based assessment is an important skill
Mental Health and Substance Abuse professionals are both used to contracting but often in different ways. Cooperation between disciplines is usually necessary to achieve optimum results
Contingent learning is often a form of contracting and is crucial to advancing treatment goals

20. Principle # 5
When psychiatric and substance disorders coexist, both disorders should be considered primary.
Diagnosed psychiatric illness receives the most clinically effective psychopharmacologic strategy available regardless of status of the co morbid substance disorder - special considerations apply to the use of potentially addictive medications that may have psychiatric indications such as benzo’s or stimulants

21. Principle # 6
Both serious mental illness and substance dependence disorders are primary biopsychosocial disorders that can be treated in the context of a “disease and recovery” model.
Biopsychosocial is a term that expresses the dynamic and interactive nature of various aspects of disease and recovery.
It is holistic.
Substance Abuse Relapse Prevention has long recognized the biopsychosocial aspects of the process – frequently comparing chemical dependence to diabetes and other chronic diseases.
The chronic nature of mental illness lends itself well to a “recovery” model.
The recovery model implies that interventions are not only diagnosis specific, but also specific to phase of recovery and stage of change.

22. Phases of Recovery Acute Stabilization (Detoxification)
Engagement/Motivational Enhancement
Active Treatment/Prolonged Stabilization
Rehabilitation/Recovery
(Relapse Prevention)
Stage of Change and Phase of Recovery should be harmonious with each other

23. Principle # 7
There is no one correct approach to individuals with co-occurring disorders.
This fact dictates a good strength based assessment in order to determine effective approach and satisfactory outcomes

24. Principle # 8
Clinical outcomes for client with co-occurring disorders must also be individualized.
What do you consider success. Needs to be decided for each individual client
Often needs to be re-defined during treatment - different outcomes for different stages of treatment
May include reduction in symptoms or use of substances, increases in level of functioning, increase in disease management skills, movement through Phases of Treatment or Levels of Change.