Concurrent Disorders: A Community Response

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Concurrent Disorders A Community Response
June 2, 2008 Addictions Ontario

• Allison Potts, MSW, RSW
• Concurrent Disorders System Integration
  Consultant
• Pinewood Centre of Lakeridge Health
• apotts_at_lakeridgehealth.on.ca

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A plan for today

• Check in for shared starting point
• The Who The What of change
• Provide 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 home messages

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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
• Community Health Centres
• And on

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Any Face Can Be The Face of Concurrent Disorders
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Kurt Cobain
ADD, Bipolar Mood Disorder and Substance
Dependence
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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 provide good service to this
  population?

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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 disorders
• The number of people affected by mental health
  and substance use problems is substantial and
  individuals with CD have reported that treatment
  is disjointed and unwelcoming
• Concurrent Disorders are associated with high
  rates of attrition, missed appointments, costly
  treatment, poor medication compliance, relapse
  and readmissions

• Individuals often fall through the cracks of a
  fragmented system

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Current Research on CD

• Prevalence,
• What Do We Do?,
• What is Best to Do?

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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 screened for at
  all

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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.

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How many??

• Among 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, 47 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, O'Grady, Bartha Parker, 2004

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Historically, Individuals With CD Have
Encountered a Treatment System that is Disjointed
and Unwelcoming

• Sequential Treatment Patients frequently
  experienced a ping pong effect of moving
  between components of the system that are
  unconnected and uncoordinated
• Parallel Treatment Simultaneous treatment
  occurring without consultation or collaboration
  resulting in high potential for conflicting
  treatment plans, over-servicing while
  under-providing
• Closed 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
difficulties, homelessness, underemployment,
poverty, social isolation and loss of hope
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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 than 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 research to be done on complex
  samplesCD

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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
• Several 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
  Techniques
• Drake, R., Mueser, K., Brunette, M., McHugo, G.
  2004

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Considering a Model for Change
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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 population
• Dr. K. Minkoff

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Rationale for System Design (and change)

• CD as an expectation 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 job, but
  better utilizing these programs and matching
  services to determine most appropriate
  interventions

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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 provision 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 used to develop and implement an
  integrated treatment plan.
• Health Canada 2002

Moving Forward Together
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• 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

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A Four Quadrant Model of Concurrent Disorders
Quadrant 2 CD Capable services delivered to individuals with high severity of substance use issues and low severity of mental illness. Consultation/Collaboration Quadrant 4 Coordinated CD capable and enhanced services are delivered to individuals with high severity of both substance use and mental illness. Integration
Quadrant 1 CD Capable services delivered to individuals with low severity of both mental illness and substance use. Care is provided throughout the health care system and all points of entry should support recovery and use of consultation. Quadrant 3 CD Capable services delivered to individuals with high severity of mental illness and low severity of substance use. Consultation/Collaboration
HIGH
Severity of Substance Use
LOW
LOW Severity of Mental Illness
HIGH
Adapted from Several Sources
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Four Basic Characteristics of the CCISC Model
(Comprehensive, Continuous, Integrated System of
Care)

• System Level Change
• Efficient Use of Existing Resources
• Best Practices with a recognition that this is
  not a homogenous group
• Integrated Treatment Philosophy

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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
• Flexibility 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 functioning,
  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

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Keys to Implementation of the CCISC Model

• Top-down/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 Planning
• Train-the-Trainers
• Minkoff Cline, 2003 Presentation

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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 planning and
  ongoing reassessment

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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)
  ICRC/AODA (www.icrcaoda.org)
• All of the Above

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Co-FitTM, COMPASSTM and CODE-CATTM

• A tool-kit developed (and licensed) by Minkoff
  and Cline that provides assessment of multiple
  levels of the system
• All items are rated on Likert scales and are
  organized into various categories related to each
  level of service and appropriate focus areas

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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

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So, how did all this come together in Durham?
And Where is Durham, anyway?
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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
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The Durham Region Experience - Context

• 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

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The Durham 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

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The Durham Region Experience - Response

• How we began
• Achieved funding for cross sector 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

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The Durham Region Experience - Response

• Think tanks held with over 40 agencies
  represented
• May 2005 - First focused on identifying 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 further
  development

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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 needs assessment that lead
  to establishment of training subgroup and a
  series of educational sessions aimed at enhancing
  the capacity of front-line staff

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Concurrent Disorders Network of Durham Region

• Key Goals
• Support Coordinated system and policy development
  within Durham Region across agencies, sectors,
  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 with regard to
  provincial policy development
• To facilitate Welcoming Strategies that will
  improve quality of care

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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 significant system buy in to the
  concepts presented and a consensus to develop a
  Charter document as recommended by Dr. Minkoff
  this was a process!

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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
  how to improve
• This is a GROWTH PROCESS and will take time

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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 on Welcoming

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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.

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Elements of Welcoming

• Reception
• Tone of voice
• Right 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

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The Durham Welcoming Focus Group Research

• Focus group interviewing was selected for this
  qualitative 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 groups
• 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 N90
  is required for completion
• Sessions are being audiotaped and later
  transcribed and group notes are also taken

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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 with Dr. Minkoff in May 2006 and
  had a completed document, ready to launch on
  April 2, 2007

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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 Region
• 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 Youth Centre,
  CHIMO Youth and Family Services, Fernie House,
  Community Care Durham COPE program, Durham
  Mental Health Services, Durham Regional Police
  Services

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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 apotts_at_lakeridgehealth.on.c
a
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Key Focus Maintaining Emphasis on System
Integration and Growth Process

• Adherence to System-wide Charter and commitment
  to a Continuous, Comprehensive, Integrated System
  of Care (Minkoff)
• System-wide screening for concurrent disorders
  enable appropriate treatment matching
• Utilizing the Quadrant Model of Concurrent
  Disorders to determine system response and
  requirements, making appropriate use of available
  resources
• A focus on Stigma and Welcoming across the system
• Ongoing system wide capacity building through
  on-site Concurrent Disorder Champions providing
  Cross-Training, and utilizing system and
  organizational assessment tools to develop
  focused action plans to increase CD capacity

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What is CD Capacity Building?

• Enhancing and Developing Skills, Influencing
  Change in Organizational Structures, and a
  Commitment to Overall Health Improvement
• Hawe et. al. 2000
• Addressing the Gap between mental health and
  addictions treatment
• Building on the strengths of current services and
  programs
• Broadening the Base of treatment and increasing
  existing capacity

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Components of CD Capacity Building

• System based structures, procedures, policies
  and practices (important to have top level buy
  in)
• Resource level redirection of
• Clinician Team based support, information,
  resources and commitment
• Partnerships Collaboration
• Development of Leadership

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What can be gained from increased CD Capacity?

• Reduced Stigma
• Improved treatment outcomes
• Improved Screening Identification
• Better clinical coordination
• Enhanced professional development for staff
• Increased job satisfaction

A way to enhance a clients treatment
team CD Capacity Building Team Member
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The Important Link to the CD Network

• Ongoing Feedback Loops
• Team members will feel heard
• Transfer of knowledge and potential for system
  influence

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Developing a Team

• Advertising
• Membership expectations
• Benefits of membership
• Establishing meeting times
• Shared ownership
• Limiting strains on time

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Regional Capacity Building Team Logistics

• Front line workers from mental health and
  addictions services
• Representing youth and adult services
• Monthly meetings rotating bimonthly between CD
  related topics and clinical case reviews
• A new openness with information, resources,
  transferrable education sessions a network of
  lunch and learn sessions being encouraged
• Supported by a Terms of Reference

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From a member on the CD Capacity Building Team

• As a professional in the addictions field, I
  need to tap into the needs and challenges facing
  other professionals in a multitude of different
  disciplines, in the mental health field. 
  Participation in the CD Capacity Building team
  allows me direct access to a diversity of 
  talents".

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Functions of the Team

• Share clinically relevant information regarding
  service provision to clients with CD
• Enhance and support capacity development within
  the member agencies by a continuous feedback loop
  of clinical and systemic information relevant to
  this population
• Communicate relevant clinical issues that relate
  to system innovations, opportunities, training
  needs and barriers to the CD Network of Durham
  Region
• Disseminate educational resources and tools to
• contribute to capacity building across agencies,
  and sectors in Durham Region

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Enhancing Capacity with Individual Agency
Consultations

• Tailored support to agencies that have signed the
  Charter
• Utilizing Screening tools
• Training on street drugs 101
• Case reviews
• Utilization of COMPASSTM tool
• Education
• Front-Line Buy-in (dont underestimate the
  importance of this)
• CE LHIN-wide conference in April 2008

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Consumer Involvement and Feedback

• Active Advocacy on the CD Network
• Difference between representative and advocate
• Focus Group Research

The Consumer Representative on the CD Network
shares these priorities

• Reduce the Stigma and the Secrecy surrounding
  mental illness and substance use so that all
  aspects of the treatment system support long term
  recovery
• Welcome those seeking treatment and treat each
  door of the system as no wrong door
• More integration of services to ensure
  clients needs are appropriately treated,
  including long term support and  community based
  case management services

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Ongoing and Next Steps

• Living the process being aware of small steps
  of change
• Bridging the knowing doing gap
• Acknowledging and implementing welcoming
  practices
• CD Capacity Building Team continuing to grow
• Development of Training Modules Shared Core
  Competencies and beyond with focus on Charter
  organizations
• Increased consumer feedback and representation on
  CD Network
• Ongoing support of use of screening tools in
  agencies the region

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What can hold growth back?

• Working in Silos
• Client ownership
• Stigma
• Perceptions, lack of information, need for
  co-training
• Fear (for jobs, for funding, of personal and
  agency limitations)

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What is your next step?

• Do you already have a network?
• Are there individuals funded to do CD work that
  could focus on system more?
• Quick wins for your community?
• What question were you hoping would be answered
  here?

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References

• Boyle, P. and Kroon, H. Integrated Dual Disorder
  Treatment International Journal of Mental Health,
  35, 2, Summer 2006 70-88.
• Brems, C. et al. Comparing Depressed Psychiatric
  Inpatients with and Without Coexisting Substance
  Use Disorders Journal of Dual Diagnosis, 2 (4),
  2006, 71-78.
• Drake, R., Meuser, K., Brunette M.,McHugo, G. A
  Review of Treatments for People with Severe
  Mental Illnesses and Co-Occurring Substance Use
  Disorders Psychiatric Rehabilitation Journal,
  27-4, Spring 2004, 360-374.
• Minkoff, K and Cline, C. Changing the World The
  Design and Implementation of Comprehensive
  Continuous Integrated Systems of Care for
  Individuals with Co-occurring Disorders.
  Psychiatric Clinics of North America, 27
  (4)727-43, 2004.
• Tsanos, A. and Herie, M. A Concurrent Disorders
  Capacity Bulding Initiative in a Clinical Program
  for People with Schizophrenia, in Skinner, W.
  Treating Concurrent Disorders A Guide for
  Counsellors Ch. 16. CAMH 2005

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Resources

• Hear Me Understand Me Support Me What young
  women want you to know about depression
  Validity Team CAMH 2006
• Beyond the Label An Educational Kit to Promote
  Awareness and Understanding of the Impact of
  Stigma on People Living with Concurrent Mental
  Health and Substance Use Problems CAMH, 2005
• Best Practices Concurrent Mental Health and
  Substance Use Disorders Health Canada 2001
• The Human Face of Mental Health and Mental
  Illness in Canada Government of Canada 2006

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Websites of Interest

• www.pinewoodcentre.org
• CAMH (Centre for Addiction and Mental Health)
  www.camh.net (particularly tutorials, free PDF
  resources, etc)
• www.kenminkoff.com
• www.cmha.ca
• http//coce.samhsa.gov/cod_resources/PDF/DDCATIntr
  oVersion23.pdf (powerpoint presentation on DDCAT)

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