Implementing Integrated Dual Disorders Treatment

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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.

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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.

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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.

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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.

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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

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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

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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.

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Co-Occurring Disorders by Severity
III Less severe mental disorder - more
severe substance abuse disorder
IV More severe mental disorder/more
severe substance abuse disorder
High Severity
Alcohol and other drug abuse
I Less severe mental disorder/less
severe substance abuse disorder
II More severe mental disorder/less
severe substance abuse disorder
Mental Illness
Low Severity
High Severity
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Service Location Coordination
III Substance abuse system
IV State hospitals, jails/prisons, emergency
rooms, etc.
High Severity
Consultation
Collaboration
I Primary health care settings
II Mental health system
Integrated Services
Alcohol and other drug abuse
Mental Illness
Low Severity
High Severity
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Any Illicit Drug Use excluding marijuana 2002-2004
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Non-medical use of pain relievers
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Tobacco Use
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Serious Psychological Distress
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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.

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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
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Goal 1

• Increase continuity and treatment integration for
  persons receiving dual disorders treatment moving
  from hospital to community health and behavioral
  health.

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Goal 2

• Increase competence of staff and programs in the
  provision of IDDT among the staffs of KRCC and
  ARH-PC

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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

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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
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NIATX Technology of Change

• Change Teams
• Rapid Change Cycles
• Plan Do Study Act
• Clear AIMS
• Sustainability
• Measurement

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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

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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

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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

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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

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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

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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 HI panel weekly
• Encouraged contact with CMHC case worker prior to
  discharge
• Patient surveys showed 90 believed changes were
  beneficial

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And the results are.
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Model of Integrated Treatment Planning
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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.

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Person Centered Approach

• ASAM-PPC
• Motivational Interviewing
• Client

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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

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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

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Thanks for your attention!

• David Mathews, Ph.D. Director of Adult services
  Kentucky River Community Care, Inc.
  wdmathews_at_aol.com
• Wendy Morris, R.N., M.S.N. Executive Director
• Appalachian Regional Health Care Hazard
  Psychiatric Center
• wmorris_at_arh.org