2. Implementing Integrated Dual Disorders Treatment An Evidence Based Practices Grant from The Kentucky Department of Mental Health & Mental Retardation Services To Kentucky River Community Care Inc.

3. October 26, 20052 Overview With the assistance of an evidence based practice training grant from the KDMHMRS, KRCC and ARH-PC have undertaken training and system transformation activities aimed at improving treatment and continuity for persons with Serious mental Illness and Substance Use Disorders.

4. October 26, 20053 About Kentucky River Community Care Inc. Kentucky River Community Care, Inc., (KRCC) is a private nonprofit Community Mental Health Center dedicated to improving the health and wellbeing of the people of our region. We help individuals and families in the eight counties of the Kentucky River region by providing mental health, developmental disabilities, substance abuse and trauma services. KRCC seeks to promote public safety, boost economic wellbeing and improve community and individual quality of life.

5. October 26, 20054 About ARH-PC Appalachian Regional Healthcare, Inc. (ARH), is a non-profit healthcare system serving more than 35,000 residents in Kentucky and West Virginia. ARH provides continuity of care through a system of hospitals, clinics, home health agencies, and home care stores. ARH celebrated 50 years of service this year.

6. October 26, 20055 About ARH-PC ARH Psychiatric Center opened in the summer of 1993. It is a 100-bed distinct part unit of the ARH Regional Medical Center in Hazard, KY - the flagship facility of the organization. ARH-PC contracts with DMH to serve 21 counties, and works closely with the CMHCs in that service area. We have four units, with three distinct programs – General, Dual Diagnosis, and Rehabilitation. Average length of stay on Dual Unit is 4.5 days

7. October 26, 20056 Why Collaboration? Persons seeking treatment for co-occurring mental health and substance use disorders often find services through multiple routes such as the hospital emergency room or physical health care professionals. Collaboration means there is no wrong door to receive needed treatment

8. October 26, 20057 Approach to IDDT Implementation Historically substance abuse treatment was not extended to persons with serious mental illness. Mental health professionals did not know how to treat substance abuse and considered it a symptom of the mental illness.

9. October 26, 20058 Co-Occurring Disorders by Severity III Less severe mental disorder - more severe substance abuse disorder I Less severe mental disorder/less severe substance abuse disorder II More severe mental disorder/less severe substance abuse disorder High Severity Low SeverityHigh Severity Alcohol and other drug abuse Mental Illness IV More severe mental disorder/more severe substance abuse disorder

10. October 26, 20059 High Severity Low Severity High Severity Alcohol and other drug abuse Mental Illness III Substance abuse system I Primary health care settings II Mental health system Consultation Collaboration Integrated Services IV State hospitals, jails/prisons, emergency rooms, etc. Service Location & Coordination

11. October 26, 200510 Any Illicit Drug Use excluding marijuana 2002-2004

12. October 26, 200511 Non-medical use of pain relievers

13. October 26, 200512 Tobacco Use

14. October 26, 200513 Serious Psychological Distress

15. October 26, 200514 Co-occurring Disorders: Report to Congress 2003 Consumers bounce back and forth between the mental health and substance abuse service systems Services need to address both disorders Substance abuse and mental health disorders reinforce each other Individuals with alcohol and drug disorders are at risk for mental illness.

16. October 26, 200515 Past Year Substance Dependence or Abuse among Adults Aged 18 or Older, by Serious Mental Illness: 2001 Percent with Past Year Substance Dependence or Abuse

17. October 26, 200516 Goal 1 Increase continuity and treatment integration for persons receiving dual disorders treatment moving from hospital to community health and behavioral health.

18. October 26, 200517 Goal 2 Increase competence of staff and programs in the provision of IDDT among the staffs of KRCC and ARH-PC

19. October 26, 200518 Goal 3 Increase staff competence in planning and implementing evidence based process improvement strategies using well researched process improvement techniques such as team which include client involvement in quality improvement

20. October 26, 200519 NIATX – Process Improvement MISSION: To assist the addiction treatment community in making more efficient use of their treatment capacity and to create an infrastructure for ongoing improvements in treatment access and retention

21. October 26, 200520 NIATX Technology of Change Change Teams Rapid Change Cycles Plan Do Study Act Clear AIMS Sustainability Measurement

22. October 26, 200521 Change Teams Group of persons led by change leader who identifies. Persons close to issue under study. Client involvement key Baseline & measurement One issue, one location, one level of care. Change cycle short for each change

23. October 26, 200522 Walk - Through as Method for Identifying Improvements Staff experience what client experiences No deception involved Pairs go through process to understand and analyze Notes taken by observer Barriers to client care identified

24. October 26, 200523 Walk - through Results KRCC Referral form unavailable Staff did not know process Form did not include phone number and needed information Staff not impressed with agency process Reasons for aftercare not identified with client

25. October 26, 200524 Walk- through Results ARH-PC Extensive discharge planning process evident Limited explanation given to patient about reason for follow- up appointments Focus on mental illness symptoms and medications NA meeting schedule given, but no plan developed for which meeting to attend, or how to stay sober during interim Collaboration between ARH and KRCC not apparent Focus on immediate and short term rather than long term goals

26. October 26, 200525 KRCC Change Team Included ARH-PC staff Perry County Outpatient staff Focused on case management contact and follow up 100% of study group continued 40% of contrast group No readmissions with study group

27. October 26, 200526 ARH Change Team Multidisciplinary team from Dual Diagnosis Unit Focused on bridging gap between inpatient and community resources –Developed community resource brochure –Began giving NA schedule upon admission –Invited NA to provide H&I panel weekly –Encouraged contact with CMHC case worker prior to discharge Patient surveys showed 90% believed changes were beneficial

28. October 26, 200527 And the results are….

29. October 26, 200528 Model of Integrated Treatment Planning

30. October 26, 200529 David Mee Lee, M.D. David Mee-Lee, M.D. is a board-certified psychiatrist, and is certified by examination of the American Society of Addiction Medicine (ASAM). Past academic appointments have included clinical affiliations in the Departments of Psychiatry at Harvard University, the University of Hawaii and the University of California, Davis. Dr. Mee-Lee is involved in training and consultation full-time. For over twenty-five years, he has focused on developing and promoting innovative behavioral health treatment that values clinical integrity, high quality, and cost- consciousness. He has over twenty-five years experience with dual diagnosis (co-occurring addiction and mental illness) treatment and program development since being trained at the Ohio State University.

31. October 26, 200530 Person Centered Approach ASAM-PPC Motivational Interviewing Client

32. October 26, 200531 Training of Trainers Final Training 12/11-14/06 Key staff at KRCC and ARH Perry outpatient and Dual unit Medical Staff at both facilities in special session

33. October 26, 200532 Future Project Goals ACLADDA – Assertive Community Living for Appalachian Dually Diagnosed Adults –New CSAT/SAMHSA grant P.A.R.K. – Partnership for Advancing Recovery in Kentucky- –New Robert Wood Johnson Foundation Grant

34. October 26, 200533 Thanks for your attention! David Mathews, Ph.D. Director of Adult services Kentucky River Community Care, Inc. wdmathews@aol.com wdmathews@aol.com Wendy Morris, R.N., M.S.N. Executive Director Appalachian Regional Health Care – Hazard Psychiatric Center wmorris@arh.org