1、Concurrent Disorders: A Community Response,Allison Potts, MSW, RSW Concurrent Disorders System Integration Consultant Pinewood Centre of Lakeridge Health apottslakeridgehealth.on.ca,June 2, 2008 Addictions Ontario,A plan for today:,Check in for shared starting point The Who & The What of change Prov
2、ide overview of current research, its key findings and limitations Review Best practices for CD and Models for understanding CD Discuss CD Capability and how to enhance it within agencies and across the system Profile the CD Network of Durham Region Explore opportunities for CD System building “take
3、 home messages”,Who is included?,Community? Service providers and service consumers The broad community all citizens System? Addictions & Mental Health (youth & adult) Hospitals Police Health and Social Services Departments School Boards Shelter/Housing Support System Mutual Aid organizations Commun
4、ity Health Centres And on,Any Face Can Be The Face of Concurrent Disorders,Kurt Cobain,ADD, Bipolar Mood Disorder and Substance Dependence,What happens,when the “system” does not provide good service to individuals with co-occurring mental health and substance use problems? when the system does prov
5、ide good service to this population?,What Are Concurrent Disorders and why is this issue so important?,Concurrent Disorders (CD) refers to cases where individuals have any combination of mental health and substance use disordersThe number of people affected by mental health and substance use problem
6、s is substantial and individuals with CD have reported that treatment is disjointed and unwelcomingConcurrent Disorders are associated with high rates of attrition, missed appointments, costly treatment, poor medication compliance, relapse and readmissions,Individuals often fall through the cracks o
7、f a fragmented system,Current Research on CD,Prevalence, What Do We Do?, What is Best to Do?,Prevalence in the Population you work with?,Varies by setting Varies by psychiatric diagnosis Varies by exclusion criteria The prevalence has often been underestimated and frequently was not explored or scre
8、ened for at all,Prevalence of Concurrent Disorders,Research suggests that twenty-five to sixty percent of people who have mental health problems will also have a substance use problem during their lifetime. These percentages are similar for people who seek help for their substance use.,How many?,Amo
9、ng people who have had an anxiety disorder in their lifetime, 24% will have a substance use disorder in their lifetime. Among people who have had major depression in their lifetime, 27% will have a substance use disorder in their lifetime. Among people who have had schizophrenia in their lifetime, 4
10、7% will have a substance use disorder in their lifetime. Among people who have had bipolar disorder in their lifetime, 56% will have a substance use disorder in their lifetime Skinner, OGrady, Bartha & Parker, 2004,Historically, Individuals With CD Have Encountered a Treatment System that is Disjoin
11、ted and Unwelcoming,Sequential Treatment: Patients frequently experienced a “ping pong” effect of moving between components of the system that are unconnected and uncoordinatedParallel Treatment: Simultaneous treatment occurring without consultation or collaboration resulting in high potential for c
12、onflicting treatment plans, over-servicing while under-providingClosed doors due to Stigma associated with substance use issues and mental illness and misperception regarding inter-relatedness of CD,STIGMA relates to a reluctance to seek treatment, increased depression, suicide, relationship difficu
13、lties, homelessness, underemployment, poverty, social isolation and loss of hope,Access To Treatment,Research comparing treatment of patients with a depressive disorder and coexisting substance use issue found that they experience greater complexity of psychosocial needs and clinical presentation th
14、an those diagnosed with depression alone and they have fewer admissions and shorter lengths of stay. Brems et al 2006, Journal Of Dual Diagnosis (Research conducted in Alaska Psychiatric Institute). Barriers to research have effected the development of treatment improvements the difficulty for resea
15、rch to be done on complex samplesCD,Evidenced Based Practices for CD,The most consistent finding across recent studies is that integrated treatment programs are highly effective Ideally, integrated treatment means that the clinician weaves the treatment interventions into one coherent package Severa
16、l outpatient and residential studies also support the use of Stage-Wise treatments (based on the Transtheoretical Model of Change Prochaska & DiClemente 1984), Engagement Techniques and Motivational Counselling TechniquesDrake, R., Mueser, K., Brunette, M., & McHugo, G. 2004,Considering a Model for
17、Change,Concurrent Disorders are an Expectation, not an Exception.,This expectation must be incorporated in a welcoming manner into all clinical contact, to promote access to care and accurate identification of the populationDr. K. Minkoff,Rationale for System Design (and change),CD as an expectation
18、 in all settings, not an exception Rule it out rather than Rule it in Striving for a minimum standard of concurrent disorder capability as a mechanism for reducing the poor outcomes and high costs of concurrent disorders Includes the understanding that each program within the system has a different
19、“job”, but better utilizing these programs and matching services to determine most appropriate interventions,System Integration?,System integration means the development of enduring linkages between service providers or treatment units within a system, or across multiple systems, to facilitate the p
20、rovision of service to individuals at the local level. Mental health treatment and substance abuse treatment are, therefore, brought together by two or more clinicians/ support workers working for different treatment units or service providers. Various coordination and collaborative arrangements are
21、 used to develop and implement an integrated treatment plan. Health Canada 2002,Moving Forward Together,The Four Quadrant Model is a viable mechanism for categorizing severity of concurrent disorders for purpose of service planning and system responsibility. Dr. K. Minkoff,A Four Quadrant Model of C
22、oncurrent Disorders,Severity of Substance Use,LOW Severity of Mental Illness HIGH,LOW,HIGH,Adapted from Several Sources,Four Basic Characteristics of the CCISC Model (Comprehensive, Continuous, Integrated System of Care),System Level ChangeEfficient Use of Existing ResourcesBest Practices with a rec
23、ognition that this is not a homogenous groupIntegrated Treatment Philosophy,Eight Principles of Treatment for the CCISC,CD is an expectation not an exception The use of the Quadrant model can help guide service planning and tx matching The importance of empathy, hope, integration and continuity Flex
24、ibility in treatment approach with variety of modalities Both MI and SA should be considered primary when they coexist A model which embraces the phases and stages of recovery is an appropriate framework for treating CD There is no single correct intervention for CD quadrant, diagnoses, level of fun
25、ctioning, phase/stage of recovery or change, external factors all must be taken into account system components develop CD capability across the board and then cohort specific enhancements Individualized treatment goals Adapted from Minkoff & Cline 2004,Keys to Implementation of the CCISC Model,Top-d
26、own/Bottom-up Development Aligning the Parts of the System Inclusion, not Exclusion (programs and populations) Strategic Use of Leverage (Incentives, Contracts, Standards, Licensure, etc.) Outcomes and CQI (CO-FIT 100) Model Programs Evaluation of Core Competencies (COMPASS and CODECAT) “Action Plan
27、ning” Train-the-Trainers Minkoff & Cline, 2003 Presentation,Assessing and Enhancing CD Capability,A strength of this model is the ongoing assessment of CD Capability/Capacity Use of system, organization and clinician assessment tools provides for identification of strengths and weaknesses, action pl
28、anning and ongoing reassessment,Some Options for Assessing CD Capability,Internal Needs Assessments (example in CAMH CD text, or agency developed tool) Minkoff Tools CO-FIT, COMPASS and Code-CAT DDCAT Addiction Treatment focused Formal Certification (the U.S. model) IC&RC/AODA (www.icrcaoda.org) All
29、 of the Above,Co-FitTM, COMPASSTM and CODE-CATTM,A tool-kit developed (and licensed) by Minkoff and Cline that provides assessment of multiple levels of the systemAll items are rated on Likert scales and are organized into various categories related to each level of service and appropriate focus are
30、as,CO-FIT100TM,A Systems Measurement tool Divided into two main sections: Implementation and Outcome Very specific, measurable objectives that can be reviewed at regular intervals Expect low scores in the beginning (room to grow!) Action Planning & Quick Wins,So, how did all this come together in Du
31、rham?,And Where is Durham, anyway?,A recent report by the Planning Department estimates that the population of the Region of Durham was 531,000 in May 2001. A target of 760,000 people has been estimated for the number of people living in the Region by the year 2011,The Durham Region Experience - Con
32、text,CD had very limited exposure/buy-in at the agency level Child/youth and adult systems had many different focuses/mindsets about addictions An review of youth in the system showed 80% of youth have indicators of substance use problems of these, 20% actually received treatment/counselling,The Dur
33、ham Region Experience - Context,Poor linkages existed between child/youth and adult services as well as between mental health and addictions services November 2004 - New funding was announced for “community priorities”,The Durham Region Experience - Response,How we began Achieved funding for cross s
34、ector and cross system “think-tanks“ WMHC and Lakeridge partnered to bring the groups together (mainly senior staff) to examine the commonalities and differences in each system,The Durham Region Experience - Response,“Think tanks” held with over 40 agencies represented May 2005 - First focused on id
35、entifying the issue and getting “buy-in” to the need to develop a coordinated response to the problem Second session narrowed to reflect commonalities in the various represented systems and set direction for next steps Achieved agreement through all parties that a “Network” approach would facilitate
36、 further development,The Durham Region Experience First Steps for the Network,Establish a shared understanding of the issues and the role of the network in regard to those issues Develop a workplan that reflects a series of “quick wins” and longer term focuses to establish Completed an on-line “need
37、s assessment” that lead to establishment of training subgroup and a series of educational sessions aimed at enhancing the capacity of front-line staff,Concurrent Disorders Network of Durham Region,Key Goals: Support Coordinated system and policy development within Durham Region; across agencies, sec
38、tors, and ministries and actively share information regarding this client population Provide or support the provision of a forum for this client population Enhance community/system capacity by coordinating educational opportunities Support/enhance system development Provide advice/recommendations wi
39、th regard to provincial policy development To facilitate Welcoming Strategies that will improve quality of care,How Dr. Minkoff fits into the Durham Plan,Dr. Minkoff came in May 2006 and spent a day with the CD Network in addition to delivering his full day presentation to the community There was si
40、gnificant system buy in to the concepts presented and a consensus to develop a Charter document as recommended by Dr. Minkoff this was a process!,A System Review The CO-FIT,The CD Network did this exercise “item by item” Egos had to be left at the door!Low scores are to be expected and used to learn
41、 how to improveThis is a GROWTH PROCESS and will take time,Our “Quick Win” from the CO-FITTM Action Planning,Consumer Satisfaction? Have we even been asking? What is it like to enter our system? Is there leverage in feedback to make improvements to the system? RESULT: The Consumer Focus Group Study
42、on Welcoming,Definition of Welcoming,A demonstration of empathy and inclusiveness in all clinical encounters where service providers, at every entry point, are attentive and responsive to client needs and facilitate prompt and appropriate service.,Elements of Welcoming,Reception Tone of voice Right
43、to service Openness Hopeful attitude toward recovery Consistent Approach Acknowledgement of Family members and S.O. Empathic Explanation of process Physical Environment reading material, information,The Durham Welcoming Focus Group Research,Focus group interviewing was selected for this qualitative
44、research as it can be well suited to obtaining several perspectives about a single topic The research proposal passed the Research Ethics Board of Lakeridge Health in September 2007 Some established groupings of individuals as well as inviting participation from individuals outside of established gr
45、oups Participants (who have accessed the system in the last 6 mos) will be asked their overall impression of receptiveness from the system, a brief questionnaire using a Likert scale is also administered at the beginning of each session Three groups have been conducted to date, an N=90 is required f
46、or completion Sessions are being audiotaped and later transcribed and group notes are also taken,The Whys & Hows of the Charter,The need for “top down” commitment to compliment the more “grass roots” approach initially taken by the network Shared understanding of the CCISC Model We began writing wit
47、h Dr. Minkoff in May 2006 and had a completed document, ready to launch on April 2, 2007,Consensus Document and Charter,Asserts that the signing partners are agreeing to support and promote the implementation of a CCISC (Comprehensive, Continuous, Integrated System of Care) approach in the Durham Re
48、gion Planning directed at achieving a minimum of concurrent disorder capable services, incorporating evidenced-based practices across all components of the broader system Signed by: WMHC, Lakeridge Health, CMHA Durham, Social Services Department Region of Durham, Rouge Valley Health Centre, The Yout
49、h Centre, CHIMO Youth and Family Services, Fernie House, Community Care Durham COPE program, Durham Mental Health Services, Durham Regional Police Services,The Charter in Practical Terms,The Charter is based on Dr. K. Minkoffs model Welcoming Evidence Based Acknowledgement and Utilization of the Quadrant model Policy Based Consensus Based Change directed to four areas: system, program, clinical practice, clinician,Email me for a copy apottslakeridgehealth.on.ca,Key Focus: Maintaining Emphasis on System Integration and Growth Process,
