Best Practices in Native Communities: Strengthening Our System of Care The Forum

1. The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Best Practices in Native Communities: Strengthening Our System of Care The Forum San Diego. California June 27, 2005 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Laura Loudon, MS Toma Timothy Michelle Singer

2. For information, contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org

3. Best Practices Overview

4. Disconnect Between Drug/Alcohol/ Mental Health • Professionals are undertrained in at least one of the domains • Patients are underdiagnosed • Patients are undertreated • None integrates well with medical and social service

5. Difficulties of Program Integration • Separate funding streams and coverage gaps • Agency turf issues • Different treatment philosophies • Different training philosophies • Lack of resources • Poor cross training • Consumer and family barriers

6. Best Practices: Historical Evolution • Agencies: IOM, I.H.S., NIAAA, NIDA, NIMH, SAMHSA, NIAAA, VAMC • Businesses: Managed care, economics • Quality care, effectiveness care

7. Treatment Brief Intervention Universal/Selective Prevention Spectrum of Intervention Responses Thresholds for Action No Problems Mild Problems Severe Problems Moderate Problems

8. Alcohol/Drug Treatment Core Components and Comprehensive Services Group/Individual Counseling Urine Monitoring Core Treatment Abstinence Based Case Management Intake Assessment Pharmaco-therapy Continuing Care Treatment Plans Self-Help (AA/NA) Medical Financial Mental Health Housing & Transportation Vocational Child Care Educational Family Legal AIDS / HIV Risks Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB)

9. How Are Evidence-Based Practices Documented? Gold Standard • Multiple randomized clinical trials Silver Standard • Consensus reviews of available science Bronze Standard • Expert opinion based on clinical observation (Drake, et al. 2001. Implementing evidence based practices in routine mental health service settings. Psychiatric Services, 52, 179 – 182)

10. Three Types of Treatment Have Demonstrated Similar Success Rates Treatments Success Rates • Cognitive behavior therapy • Learning skills to cope with situations that precipitate drinking • 12-step programs • Alcoholism is a disease • AA involvement • Motivational-enhancement therapy • Motivational interviewing outlined in guidebooks At 1 Year • Abstinent 85% of days (vs. 20%–30% of days at start of study) At 3 Years • 2/3 still abstinent Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607

11. A Selected Sample of Manuals • Time Out! For Me - Workshop for Women • Time Out! For Men • Cognitive Behavior Therapy for Adolescents • Multidimensional Family Therapy • Enhancing Motivation for Change • Mapping New Roads to Recovery

12. 1. Gather information 2. Express concern 3. Provide feedback 4. Express empathy 5. Offer help 6. Know local referral options 7. Reinforce self worth 8. Assist with a plan 9. Follow up Nine Steps to Help Prevent Long-Term Disability from Unhealthy Alcohol/Drug Use

13. Integrated Treatment “Any mechanism by which treatment interventions for co-occurring disorders are combined within the context of a primary treatment relationship or service setting.” -CSAT

17. Agencies Involved in B.H. Delivery 1. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 2. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 3. Tribal Health 4. Urban Indian Health • State and Local Agencies • Federal Agencies: SAMHSA, VAMC

18. AmericanIndians and Alaska Natives • Have same health disorders as general population • Greater prevalence • Greater severity • Much less access to Tx • Cultural relevance more challenging • Social context disintegrated

19. Behavioral Health Issues • Addiction • Crow Nation • Suicide • Standing Rock • Red Lake • Domestic Violence • Co morbidity • Across Regions Chart indicates deaths per 1000 people. Blue = AI, Burgundy = U.S. Average

20. Different goals Resource silos One size fits all Activity-driven How is it working? (Carl Bell, 7/03)

21. Best Practice Culturally specific Outcome driven Integrating resources We need Collaboration, Integration, and Synergy : Community Mobilization (Carl Bell, 7/03)

22. Definitions: Indigenous Knowledge • Is local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, which is used as a basis for decision-making for all of life’s needs.

23. Definitions: Traditional Medicine • The sum total of health knowledge, skills and practices based upon theories, beliefs and experiences indigenous to different cultures…used in the maintenance of health. WHO 2002

24. Definitions: Evidence-based Practices • Interventions that show consistent scientific evidence of improving a person’s outcome of treatment and/or prevention in controlled settings. SAMHSA 2003

25. Definitions: Best Practices • Examples and cases that illustrate the use of community knowledge and science in developing cost effective and sustainable survival strategies to overcome a chronic illness. WHO 2002

26. World Conference on Science A partnership begins! • Recommended that scientific and indigenous knowledge be integrated in interdisciplinary projects dealing with culture, environment and chronic illness. 1999

27. ID Best Practice Best Practice Clinical/Services Research Mainstream Practice Traditional Healing

28. Circle of Care Traditional Healers Child & Adolescent Programs Primary Care Best Practices A&D Programs Boarding Schools Colleges & Universities Prevention Programs Emergency Rooms

29. Community MobilizationPartnered Collaboration Community-Based Organizations Grassroots Groups Treatment-Education-Research