Breaking Down Barriers: Providing Integrated Care for Individuals with Severe Mental Illness and Substance Use Disorders Ken Bachrach, Ph.D. Debbie Innes-Gomberg,

Breaking Down Barriers: Providing Breaking Down Barriers: Providing Integrated Care for Individuals with Integrated Care for Individuals with

Severe Mental Illness and Substance Severe Mental Illness and Substance Use DisordersUse Disorders

Ken Bachrach, Ph.D. Ken Bachrach, Ph.D. Debbie Innes-Gomberg, Ph.D.Debbie Innes-Gomberg, Ph.D.

Monica Weil, Psy.D.Monica Weil, Psy.D.Martin Hernandez, MSWMartin Hernandez, MSW

The Mental Health Services The Mental Health Services Act Act

Proposition 63 Passed November, Proposition 63 Passed November, 20042004

Identifies 4 distinct age groups:Identifies 4 distinct age groups:

Children Children 0 -150 -15

Transition Age YouthTransition Age Youth 16-2516-25

AdultsAdults 26-5926-59

Older AdultsOlder Adults 60 +60 +

MHSA Philosophy MHSA Philosophy

Goal is to transform the mental health Goal is to transform the mental health system system

An inclusive planning processAn inclusive planning process Fund or expand programs that use proven Fund or expand programs that use proven

service modelsservice models Assure accountability by collecting data on Assure accountability by collecting data on

outcomesoutcomes Do whatever it takes to support clients to Do whatever it takes to support clients to

achieve recoveryachieve recovery

Components of MHSAComponents of MHSA

PlanningPlanning Community Services and SupportsCommunity Services and Supports

FSP and Systems DevelopmentFSP and Systems Development Prevention and Early InterventionPrevention and Early Intervention Capital Facilities and TechnologyCapital Facilities and Technology Workforce, Education and TrainingWorkforce, Education and Training InnovationInnovation

Full Service PartnershipsFull Service PartnershipsAdultsAdults

Adults who are a severe mental illness and who Adults who are a severe mental illness and who are:are:

HomelessHomeless In jailIn jail Frequent users of psychiatric hospitals or ERsFrequent users of psychiatric hospitals or ERs In institutions (IMDs, State Hospitals)In institutions (IMDs, State Hospitals) Being cared for by families but in the absence Being cared for by families but in the absence

of the family would be at risk of the above.of the family would be at risk of the above.

FSP ServicesFSP ServicesWhatever it TakesWhatever it Takes

Individualized, comprehensive treatment Individualized, comprehensive treatment and support focused on recoveryand support focused on recovery

1:15 maximum staff to client ratio1:15 maximum staff to client ratio Multi-disciplinary daily team meetingsMulti-disciplinary daily team meetings 24/7 availability for crises24/7 availability for crises Field-based service approachField-based service approach Peer support servicesPeer support services Integrated COD servicesIntegrated COD services Housing and employment assistanceHousing and employment assistance

Services Provided in Services Provided in Residential Drug and Alcohol Residential Drug and Alcohol

TreatmentTreatment Assessment & Treatment PlanningAssessment & Treatment Planning Individual and Group CounselingIndividual and Group Counseling Addiction and Recovery ServicesAddiction and Recovery Services Social ServicesSocial Services Community LinkagesCommunity Linkages Discharge PlanningDischarge Planning

INTAKE•Assess need for treatmentand determine level of care• Complete required forms

AdmitPatient

Preliminary TreatmentPlan within24 hours

COMPLETE ASSESSMENTS:

•ASI•Psych Symptom Chklist•Family/SO•Nutritional Screening•History & Physical•Psychiatric

INTEGRATEDSUMMARY

COMPLETE TREATMENT

PLAN

INITIAL CASECONFERENCE

TREATMENTPLAN

UPDATE / PTPROGRESS

REVIEW

TREATMENT PLANNING PROCESS

GroupsGroups

Educational (Addiction Education)Educational (Addiction Education) Psychoeducational (Relapse Psychoeducational (Relapse

Prevention)Prevention) Process (Recovery Issues; Men’s / Process (Recovery Issues; Men’s /

Women’s Group)Women’s Group)

Core GroupsCore Groups

Addiction EducationAddiction Education Family EducationFamily Education Relapse PreventionRelapse Prevention Self-Help OrientationSelf-Help Orientation Recovery IssuesRecovery Issues Multi-Family GroupMulti-Family Group

Residential ElectivesResidential Electives

Stress ManagementStress Management Spirituality GroupSpirituality Group Depression ManagementDepression Management Trauma Group Trauma Group (separate for men & women)(separate for men & women) Grief & LossGrief & Loss Anger ManagementAnger Management Recreational Therapy / Leisure EducationRecreational Therapy / Leisure Education

Residential Drug Treatment Residential Drug Treatment RecipientsRecipients

Often have a long history of substance Often have a long history of substance abuse and documented severe and abuse and documented severe and persistent psychiatric disorderpersistent psychiatric disorder

Often homeless or recently released Often homeless or recently released from a psychiatric hospitalization from a psychiatric hospitalization

Unable to stop their substance use on Unable to stop their substance use on an outpatient basis, but don’t meet an outpatient basis, but don’t meet criteria for a psychiatric hospitalizationcriteria for a psychiatric hospitalization

Four-Quadrant Framework for Four-Quadrant Framework for CODCOD

Source: NASMHPD, NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002Source: NASMHPD, NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002

Less severemental disorder/

less severe substanceabuse disorder

More severemental disorder/

less severe substanceabuse disorder

More severemental disorder/

more severe substance

abuse disorder

Less severemental disorder/

more severe substance

abuse disorder

High severity

High severity

Lowseverity

Service Delivery for CODService Delivery for COD

Consultation between systems

Generally not eligible for public alcohol/drug or mental health services

Low to Moderate Psychiatric Symptoms/Disorders

And

Low to Moderate Severity Substance Issues/Disorders

Services provided in outpatient chemical dependency or mental health system

LOW - LOW HIGH - LOW

Collaboration between systems

Eligible for public mental health services but not alcohol/drug services

High Severity Psychiatric Symptoms/Disorders

And

Low to Moderate Severity Substance Issues/Disorders

Services provided in outpatient and inpatient mental health system

LOW - HIGH

Collaboration between systems

Eligible for public alcohol/drug services but not mental health services

Low to Moderate Psychiatric Symptoms/Disorders

And

High Severity Substance Issues/Disorders

Services provided in outpatient and inpatient chemical dependency system

HIGH - HIGH

Integration of services

Eligible for public alcohol/drug and mental health services

High Severity Psychiatric Symptoms/Disorders

And

High Severity Substance Issues/Disorders

Services provided in specialized treatment programs with cross-trained staff or multidisciplinary teams

Source: Ries, 2004

FSP & Concurrent Residential Drug FSP & Concurrent Residential Drug TreatmentTreatment

A model for integrated servicesA model for integrated services Provides a safe environment to Provides a safe environment to

address substance use and mental address substance use and mental health symptoms and to create a health symptoms and to create a joint treatment planjoint treatment plan

The Pilot StudyThe Pilot Study

Purpose – To identify promising Purpose – To identify promising practices supporting integrated services practices supporting integrated services for clients with co-occurring disordersfor clients with co-occurring disorders

What added value does the FSP team What added value does the FSP team serve while an FSP client is in residential serve while an FSP client is in residential drug/alcohol treatment?drug/alcohol treatment?

What are the unique roles of the FSP What are the unique roles of the FSP team and the residential team?team and the residential team?

How do the teams work together best?How do the teams work together best?

FSP Clinical Case ConferencesFSP Clinical Case Conferences

2 weeks after an adult FSP enrollee 2 weeks after an adult FSP enrollee enters residential drug/alcohol enters residential drug/alcohol treatment, a clinical case conference treatment, a clinical case conference will be initiated by the FSP program or will be initiated by the FSP program or the Service Area District Chief.the Service Area District Chief.

Clinical case conferences continue Clinical case conferences continue every 30 days until the client is every 30 days until the client is discharged from the residential discharged from the residential program.program.

Clinical Case ConferenceClinical Case Conference

Review treatment plan- client stage Review treatment plan- client stage of recovery and intervention of recovery and intervention strategiesstrategies

Identify unique services provided by Identify unique services provided by FSP team and residential treatment FSP team and residential treatment team.team.

Ensure services are not duplicatedEnsure services are not duplicated

Case Example #1Case Example #1

Mr. Vinnie Boom BotzMr. Vinnie Boom Botz 52 year old Hispanic male who has been diagnosed 52 year old Hispanic male who has been diagnosed

with Schizoaffective Disorder and alcohol with Schizoaffective Disorder and alcohol dependence.dependence.

Long history of ETOH dependenceLong history of ETOH dependence Patient suffers from head injury as a result of Patient suffers from head injury as a result of

sustaining a beating while intoxicated and sustaining a beating while intoxicated and homeless.homeless.

Due to patient’s Organic Brain Disorder, frequent Due to patient’s Organic Brain Disorder, frequent relapse on alcohol and other substances of abuse – relapse on alcohol and other substances of abuse – patient required stabilization on the residential unit.patient required stabilization on the residential unit.

Vinnie, ContinuedVinnie, Continued

Case consultation began immediately Case consultation began immediately between FSP Case Manager, FSP clinician between FSP Case Manager, FSP clinician and residential clinician and counselor.and residential clinician and counselor.

DMH was consulted as wellDMH was consulted as well As a result, patient was given a As a result, patient was given a

neuropsychological testing battery and neuropsychological testing battery and reports were written to advocate for reports were written to advocate for patient to receive SSI.patient to receive SSI.

Patient was approved for SSI.Patient was approved for SSI.

Vinnie, Cont.Vinnie, Cont.

Patient is currently living in sober livingPatient is currently living in sober living Patient attends community meetingsPatient attends community meetings Patient continues with FSP case Patient continues with FSP case

management and therapeutic servicesmanagement and therapeutic services Patient’s SSI payments are administered by Patient’s SSI payments are administered by

a third party as he is unable to manage his a third party as he is unable to manage his own finances.own finances.

Patient is receiving dental and medical Patient is receiving dental and medical servicesservices

Vinnie, Cont.Vinnie, Cont.

Patient has a strong connection with Patient has a strong connection with residential unit and with treatment residential unit and with treatment facility.facility.

Auditory and visual hallucinations Auditory and visual hallucinations remain, but have decreased in both remain, but have decreased in both quality and quantityquality and quantity

He has been able to recognize that He has been able to recognize that his hallucinations are not reality and his hallucinations are not reality and respond more appropriately to them.respond more appropriately to them.

Case Example #2Case Example #2

Mr. Jimmy RodzMr. Jimmy Rodz 27 year old Hispanic male diagnosed with 27 year old Hispanic male diagnosed with

Psychotic Disorder NOS and Poly-substance abuse Psychotic Disorder NOS and Poly-substance abuse and Methamphetamine Dependenceand Methamphetamine Dependence

Has short but extensive history of abusing drugsHas short but extensive history of abusing drugs Prior to age 18, client had been doing well, Prior to age 18, client had been doing well,

enrolled in college, and wanted to be a peace enrolled in college, and wanted to be a peace officer.officer.

Mother explained that she believes that the Mother explained that she believes that the community they lived in (high drug use), possibly community they lived in (high drug use), possibly influenced his extensive drug useinfluenced his extensive drug use

Jimmy Cont.Jimmy Cont.

Prior to FSP services, he was accepting sporadic mental Prior to FSP services, he was accepting sporadic mental health services due to client’s non-compliance with health services due to client’s non-compliance with recommended treatment. recommended treatment.

Client had numerous psychiatric hospitalizations while Client had numerous psychiatric hospitalizations while he was under the influence or coming down from using.he was under the influence or coming down from using.

When enrolled into FSP services, program also enrolled When enrolled into FSP services, program also enrolled and placed in a residential drug treatment facility.and placed in a residential drug treatment facility.

Client responded well to the structured treatment and Client responded well to the structured treatment and the Co-Occurring Disorder Treatment.the Co-Occurring Disorder Treatment.

FSP Program held weekly team meeting at which client’s FSP Program held weekly team meeting at which client’s case was discussed, and bi-monthly meetings with case was discussed, and bi-monthly meetings with residential drug treatment program and FSP treatment residential drug treatment program and FSP treatment team.team.

Jimmy Cont.Jimmy Cont.

Client graduated residential drug treatment Client graduated residential drug treatment and moved on to sober living. and moved on to sober living.

He continues to received FSP services and has He continues to received FSP services and has moved to independent living. moved to independent living.

Client has strong relationship with substance Client has strong relationship with substance abuse support groups in the community. abuse support groups in the community.

Currently, client has full-time employment and Currently, client has full-time employment and is planning to enroll in college. Client is planning to enroll in college. Client continues to remain sober since entering FSP continues to remain sober since entering FSP Program and Residential Drug Treatment.Program and Residential Drug Treatment.

Lessons LearnedLessons Learned

It is important to have available short-term It is important to have available short-term residential drug treatment in the continuum residential drug treatment in the continuum of care for individuals with severe mental of care for individuals with severe mental illness and severe substance abuse illness and severe substance abuse problemsproblems

Short-term residential drug treatment can Short-term residential drug treatment can provide the opportunity to conduct a provide the opportunity to conduct a thorough assessment of the individual’s thorough assessment of the individual’s psychiatric and psychosocial functioning psychiatric and psychosocial functioning when not using substanceswhen not using substances that is rarely that is rarely possible on an outpatient basis. possible on an outpatient basis.

Lessons LearnedLessons Learned

Mental health services can be initiated or Mental health services can be initiated or continued in an environment where their continued in an environment where their effectiveness can be better evaluated, given effectiveness can be better evaluated, given the controlled environment of residential the controlled environment of residential carecare

Mental health services can be coordinated Mental health services can be coordinated during treatment and continued after leaving during treatment and continued after leaving residential care in a seamless fashionresidential care in a seamless fashion

Frequent communication between AOD and Frequent communication between AOD and DMH providers is critical to provide DMH providers is critical to provide coordinated and integrated care. coordinated and integrated care.

Next StepsNext Steps

Expand the number of AOD providers Expand the number of AOD providers who can work with FSP programswho can work with FSP programs

Continue to refine and improve Continue to refine and improve communication and coordination of communication and coordination of carecare

Evaluate the effectiveness of Evaluate the effectiveness of providing residential AOD services in providing residential AOD services in improving outcomesimproving outcomes