Building Integrated

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Building Integrated Coordinated Services for
People With Co-Occurring Disorders

• Making Waves for Change
• CMHA National Conference
• August 2008

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Presented by

• Nicole Chammartin
• CMHA Winnipeg
• Kelly Southworth
• Winnipeg Regional Health Authority,
• Community Mental Health Program

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Co-Occurring Mental Health and Substance Use
Disorders Initiative (CODI)

• Manitoba

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Terminology

• Co-Occurring Disorders

• Concurrent Disorders
• Dual Disorders
• Dual Diagnosis
• Co-existing Disorders
• Co-morbid Disorders

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CODI

• Specialized Services
• or
• Systems Change?

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Expert Consensus on Need

• The number of people with co-occurring disorders
  tends to be highly underestimated.
• These individuals
• Are highest in risk for harm
• Incur the highest service costs
• Experience the poorest outcomes
• K. Minkoff, MD

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Increased Risk for Harms

• When compared with people who have a mental
  health problem alone, people with dual diagnosis
  are more likely to have
• Increased likelihood of suicide
• More severe mental health problems
• Homelessness and unstable housing
• Increased risk of victimization
• Increased risk for HIV infection
• More contact with the criminal justice system
• Increased risk of being violent
• Royal College of Psychiatrists, 2002

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Common Barriers to Service

• Difficulty in diagnosing co-occurring disorders
• Most programs are not designed to accommodate
  clients with CODs
• Lack of specialized services and cross-trained
  clinicians
• Differences between MH and SU treatment
  philosophy and methods
• Lack of common assessment language and tools
  between the MH and SU systems
• Organizational and funding barriers to service
  collaboration between what are fundamentally
  separate (non)service systems

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Decision Systems Change

• CODs are common, diverse, complex
• No one specialized program could meet all needs
  for all clients
• If everyone in the service systems worked a
  little bit differently, great improvements for
  people could be achieved

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CODI

• Project Purposes and Goals

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CODI Vision

• CODI is a strength-based, client directed, and
  recovery-oriented service model, where the focus
  is on helping to facilitate positive recovery
  experiences and outcomes for the client in spite
  of service and system limitations.

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Overall Purposes

• To resolve system level, service coordination
  issues that frequently result in ineffective care
  and poor treatment outcomes.
• To enhance system capacity to deliver effective,
  coordinated care, and to improve treatment
  outcomes.

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Goal of the Project

• To create a coordinated mental health and
  addiction service delivery system that is able
• To provide universally accessible, welcoming, and
  integrated services for persons with co-occurring
  mental health and substance use disorders, and
• Results in improved system access, seamless
  service experience, increased service
  satisfaction.

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Service Level Focus

• Supporting the development of integrated and
  coordinated care at the level of clinical
  practice
• With system level supports
• But without system level administrative
  re-organization.

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Expected Outcomes

• Universally welcoming, dual diagnoses capable
  services, anchored in program policy and
  procedures
• Improved access to and coordination of services
• Cross-trained clinicians
• Enhanced specialized care services
• Improved system data
• Improved outcomes for clients
• Increased satisfaction for clients and families

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CODI

• Project History, Partners, and Structure

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Sponsoring / Supporting Partners

• Manitoba Health and Healthy Living, Mental Health
  and Addictions Branch
• Manitobas 11 Regional Health Authorities
• Addictions Foundation of Manitoba

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Manitobas 11 Regional Health Authorities
Mainly responsible for the delivery of Mental
Health services
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AFMs 3 Provincial Service Regions
Leading provider of Addiction rehabilitation
services
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Other Key Supporting Partners include

• Anxiety Disorders Association of Manitoba
• Behavioural Health Foundation Inc.
• Canadian Mental Health Association
• Manitoba Schizophrenia Society
• Mood Disorders Association of Manitoba

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Provincial CODI Structure
Assiniboine
Norman, Burntwood Churchill
Winnipeg
Parkland
North East Interlake
South East
Brandon
Central
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Project Development History

• 2001
• Interagency Planning Winnipeg Region
• 2002
• Hiring of consultants coordinator Winnipeg
  Region
• Selection training of trainers Winnipeg
• Leadership stakeholders consultations-Winnipeg
• 2003/4
• Manitoba Health initiates rollout of CODI across
  province
• Provincial competencies workshop package
  developed
• Provincial deliverables set for RHAs funded
  agencies
• 2005-7
• Province-wide staff training rollout
• Provincial CODI Policy developed
• Provincial MH data sets incorporate CODI elements

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Project Development History

• 2006
• CODI Outreach Team (WRHA CMHP)
• Specialized services consultations
• 2007
• Most participating agencies moving to
  operationalize embed CODI practice through
  development of practice guidelines
• 2008
• CODI partnership with Manitoba Justice
• 2009
• Summer Institute planned with Brandon University

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Proposed Solution

• Core Concepts

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Systems Integration ? Services Integration
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Welcoming Practice

• Wherever the client appears in the system of
  care, it is the right place for them to access
  the services of the system
• NO WRONG DOOR

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Dual Diagnosis Capability (DDC)

• Programs address CODs in their policies and
  procedures, assessment, treatment planning,
  program content and discharge planning
• Staff are able to address the interaction
  between mental and substance-related disorders
  and their effect on the patients readiness to
  changeas well as relapse and recovery
  environment issuesthrough individual and group
  program content.
• ASAM 2001

Universal Program Competency
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Dual Diagnosis Enhanced (DDE)

• Services place their primary focus on the
  integration of services for mental and
  substance-related disorders in their staffing,
  services and program content.
• ASAM 2001
• Provide unified treatment for persons with more
  severe and disabling CODs

Specialized Program Competency
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DDC Level Service IntegrationKey Service
Components

• Welcoming atmosphere
• Universal Integrated Screening
• Targeted Integrated Assessment
• Integrated service/treatment planning as
  indicated
• Appropriately adjusted service delivery
• Service coordination and care management

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Division of Responsibility By Problem Severity
Quadrant III (Low-High) Primary Locus of
Care Addiction Services System
Quadrant IV (High-High) Primary Locus of
Care Specialized (Mental Health) Services
High Severity
Quadrant II (High-Low) Primary Locus of
Care Mental Health Services System
Quadrant I (Low-Low) Locus of Care Primary
Care, Addiction or Mental Health Services
Substance Use Problem Severity
Low Severity
High Severity
Mental Health Problem Severity
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Implementing System Change

• Strategic Framework

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Basic Assumptions

• Large service organizations and service systems
  are naturally resistant to change
• Planned change requires concerted efforts to
  direct, manage and sustain change
• Sustainable change must be imbedded at all levels
  of the system, the organization and service
  practice

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System Change Requires

• Opinion leaders who endorse the change
• System administrators and program directors that
  are knowledgeable and supportive
• Policies that provide incentive for change
• Supervisors skilled in supporting new practices
• Service providers with knowledge, skills and
  attitudes consistent with new practices
• Staff and consumer input and feedback
• The Change Book, ATTC 2000

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Implementation Levels
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Implementing System Change

• A Model, Resources Tools

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The CCISC ModelKen Minkoff, MD

• Comprehensive, Continuous, Integrated System of
  Care

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CCISC Principles

• COD should be an expectation
• Universal welcoming and system access
• Empathic, hopeful and continuous relationships
• Balancing challenging and care-giving approaches
• Concurrent response to both as primary disorders
• Stage/phase-specific approaches
• Individualized service plans
• Individualized outcomes harm reduction options

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Expectations of Participating Agencies

• All funded MH SU service providers were
  expected to participate
• Changes were to be undertaken within the context
  of existing operational resources
• Changes were to be based on evidence
  consensus-based best practice principles
• Changes were to reflect an integrated service
  philosophy, common language and clinical
  information frameworks

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Assumptions

• MH and SU programs do not have to change
  dramatically in order to serve people with CODs
• Programs do not need to be fully integrated or
  fall under unified administrative authority for
  them to become effective in delivering integrated
  services
• Staff trained in either MH or SU treatment do not
  have to become experts in both specialties, but
  they do require a basic level of competency in
  the field which is not their specialty

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Consensus Agreement

• Signature indication of formal support
• CODI Consensus document outlines
• Best Practice Principles of CCISC Model
• Basic Expectations of Change Plan
• Action Expectations for agencies/programs

• Initial Action Expectations
• Assign empower process leader
• Action planning
• Staff training
• Develop welcoming policies
• Competency self-assessment
• Screening, identification reporting
• Interagency coordination collaboration

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Provincial CODI Policy 2007

• Attain and maintain co-occurring capability
  (DDC)
• Establish and implement policies and procedures
• Ensure all clients screened for COD
• Ensure all clients with positive screen receive a
  comprehensive integrated assessment
• Ensure that all clients who are assessed as
  having a COD have an integrated treatment plan
• Ensure data is collected and reported annually

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Supporting the Front Line

• Training, Networking, Resources,
  Supervision/Coaching

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The Role of Training

• Systems change involves creating a mechanism by
  which a desired change is accepted, incorporated
  and reinforced at all levels of an organization
  or system.

• Training provides a mechanism for transferring
  knowledge about the desired change and the means
  to achieve it.
• The Change Book, ATTC 2000

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Clinical Competencies, Training Guidelines,
Workshops

• Welcoming, Empathic Hopeful Stance
• COD Population Needs Barriers
• MH/SU Clinical Knowledge Best Practices
• Change Recovery Models
• Crisis Response
• Screening Assessment
• Integrated Treatment/Rehab Planning
• Coordination of Services
• Facilitation of Recovery

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CODI Workshops How they work in Winnipeg

• Common curriculum
• Sponsoring agencies fund
• Co-facilitated by MH SU
• Participating agencies provide front-line
  facilitators

• Open registration for all participating agencies
• Mix of MH SU staff in every workshop
• Not every staff takes all 10 workshops

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Winnipeg CODI Network

• Community of Practice for interested clinicians
• 30 participating organizations
• Rotating host agency plans content
• Case discussions, tour overview of services,
  video discussions, resource sharing, consumer
  presentations . . .

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CODI

• Why its working

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Strength / Success Factors

• Strong consensus on conceptual and values
  framework
• Strong commitment from sponsors, lead agencies
  individual clinician-champions
• Strong, empowered leadership/participatory
  processes
• Collaboration technician / project coordinator
• Informal Community of Practice networks
• Quality training resources committed trainers
• Funder deliverables and other reward
  incentives
• Focus of change on enabling collaborative
  practice
• Emerging clinical expertise and specialized
  self-help
• Broadly accessible clinical consultationWinnipeg

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Incremental Agency Engagement Plan-Winnipeg
Region-
Collaborating Providers -Non Mental Health Non
Addiction
All Other Mental Health and Addictions
Other Mental Health and Addictions Targeted
Stakeholders
2008
2006
2008
2006
2 0 0 2
2
3
4
Mental Health and Addiction Programs with Trainers
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CMHA Winnipeg

• How CODI works in an individual organization

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CMHA Winnipeg and CODI

• CODI Member since inception in 2001
• Offer Recovery and Rehabilitation services in
  Winnipeg (Approximately 120 clients per year)
• Historically had avoided working with clients on
  substance abuse issues (lack of expertise)
• Now identify approximately 25 of clients as
  having CODs

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CODI at CMHA Winnipeg
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CODI at CMHA Winnipeg
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CODI at CMHA Winnipeg

• Create annual agency plan for CODI
• Have incorporated CODI principles into all client
  work
• Training in house of all service RR staff for
  all CODI levels
• PROMOTE HARM REDUCTION

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CMHA Winnipeg CODI Tools

• Use of MIDAS and ILSA for screening and
  assessment (Minkoff)
• Creation of specific CODI work path
• Revamped tools to serve broader population(i.e.
  compulsive behaviours like gambling, eating
  sex)
• Creation of the Change Tool Box

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Changes Tool Box

• Created to assist clients to work through Stages
  of Change (compilation of tools)
• Can be used individually or as part of a program
• Develops personalized action plans for change
• CDs available for purchase through CMHA Winnipeg
  (www.cmhawpg.mb.ca)

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CMHA Winnipeg Outcomes

• Current outcome evaluation underway
• Reports from staff demonstrate increased
  satisfaction with work
• Reports from client demonstrate satisfaction with
  program and results

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Outcome Data- CMHA Winnipeg
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Outcome Data- CMHA Winnipeg
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CODI at CMHA Winnipeg
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CODI at CMHA Winnipeg
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Contact Us

• Nicole Chammartin
• Executive Director
• CMHA Winnipeg
• 432 Ellice Ave.
• Winnipeg, MB R3B 1Y4
• 204-982-6103
• Nicolec_at_cmhawpg.mb.ca

• Kelly Southworth
• Practice Development Coordinator
• WRHA Community Mental Health Program
• 189 Evanson St.
• Winnipeg, MB R3G 0N9
• 204-940-1695
• Ksouthworth_at_wrha.mb.ca

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Recommended Reading

• COCE Overview Papers
• The Co-Occurring Center for Excellence (COCE),
  funded through the Substance Abuse and Mental
  Health Services Administration (SAMHSA), has a
  mission to
• Receive transmit advances in treatment
• Guide enhancements in infrastructure clinical
  capacities of service systems
• Foster infusion adoption of concensus
  evidence-based COD practice
• http//www.coce.samhsa.gov/

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