INTEGRATION OF CARE FOR CO-OCCURRING DISORDERS BEGINS AT INTAKE

1. INTEGRATION OF CARE FOR CO-OCCURRING DISORDERS BEGINS AT INTAKE Roshni Chatterjee, LPC Director of Intake Community Connections Washington DC

2. Integration • Rationale • Goal • Implementation • Outcomes

3. Rationale 100% of consumers seen at intake present with a major mental illness • Schizophrenia • Bi-polar Disorder • Affective Disorders 90% of consumers at intake present with a co-occurring substance abuse disorder. • Crack • Alcohol • Marijuana • Polysubstance Intake staff needed further training in order to address the needs of this priority populations. Information gathered by the intake department will inform the agency about the prevalence and incidence of dual disorder in the referral pool and hence will impact agency wide service decisions.

4. Goal My Goal: Improve the ability of the Intake Team at Community Connections to accurately identify, assess and categorize new Dually Diagnosed (DD) clients.

5. Implementation

6. Screening 1. Interview Framework: • 95% of our consumers have co-occurring disorders. • Know your own bias. • Don’t forget to ask questions if you want the answers! • Recognize what you see. 2. MIDAS (Minkoff, K. 2001) • A self-report tool • Refers to previous six months • Any “yes” answer could indicate a problem with drugs/alcohol • Some differentiation between abuse/dependence • Some specific internal decision rules • Follow up with assessment 3. Mental Status Exam The MSE is the basis for understanding the client's presentation and beginning to conceptualize their functioning into a diagnosis.

7. Screening - The MIDAS Self Report about drug/alcohol problems Self assessment Doctor’s assessment Family’s assessment Related legal problems Complications of medical problems Interaction of drug & mental health issues Drugs to relieve MH problems Drugs worsen MH problems Problem with med compliance due to drugs Feelings of: Symptoms of withdrawal Guilt due to drug use Being out of control due to drug use Belief that one is an addict or alcoholic Self report of: Problem with provider, school, work Increase in ER visits Detox Related Psychiatric hospitalization Attendance at AA/NA Other SA Treatment

8. Orientation Rapport and Attitude Appearance Mood Affect Speech Thought Process Thought Content Dangerousness Hallucinations Insight Judgment Behavior Cognition Memory (please indicate good, fair, or impaired for each) Psychomotor Activity Sleep Appetite Substance Use General Psychiatric Condition Screening - Mental Status Exam

9. Assessment Recognizing, conceptualizing and categorizing substance abuse and mental health symptoms are key components of the intake process… • Issues in assessing co-existing disorders • Key Questions • Sub-groups of people with co-existing disorders • Stages of Change • Phases of Recovery • Stages of Treatment

10. Assessment Principles Relationship based Integrated Longitudinal Strengths Based Comprehensive Continuous Systematic *CCISC from Ken Minkoff, MD Assessment Content Strengths Symptoms Successful Treatment Stage of Change, Treatment Supports Spiritual and Cultural Framework Skills Somatic Issues Significant Problems or Contingencies Issues in Assessment*

11. Key Questions in Assessment Substance Abuse ? • When did you start using drugs? • What drugs have you used in your life? What is your drug of choice? • Are you experiencing withdraws or other medical problems? • Tell me about your treatment history… • How much clean/sober time do you have? • How easy was it for you to access services Mental Health ? • What is the presenting problem? • Are you in crisis – SI/HI? • What symptoms are you experiencing? • What medications are you taking and who is your doctor? • What is your treatment/hospitalization history? • What services are you looking for?

12. Assessing Subgroups* SUB-GROUPS OF PEOPLE WITH COEXISTING DISORDERS: Patients with “Dual Diagnosis” – combined psychiatric and substance abuse problems – who are eligible for services fall into four major Quadrants. *Minkoff, K CCiSC 2001

13. Assessing Stage of Change* In order to engage a client effectively at intake it is critical to meet the client where they are with their recovery/treatment: • Pre-contemplation • Contemplation • Preparation • Action • Evaluation *Minkoff, K & Cline, C., CCISC 2001

14. Assessing Phase of Recovery* Both substance dependence and mental illness are disorders which can be understood using a disease and recovery model with parallel phases of recovery. Recommendations made at intake about the current phase of recovery has implications for engagement and prioritizing treatment needs. • PHASE 1: Stabilization - Stabilization of active substance use or acute psychiatric symptoms • PHASE 2: Engagement/Motivational Enhancement - Engagement in treatment - Contemplation, Preparation, Persuasion • PHASE 3: Prolonged Stabilization - Active treatment, Maintenance, Relapse Prevention • PHASE 4: Recovery & Rehabilitation - Continued sobriety and stability - One year – ongoing *Minkoff, K CCiSC 2001

15. Assessing Stage of Treatment* Engagement - Lack of working alliance Early Persuasion - Working alliance with some discussion about SA and MI issues Late Persuasion - Engaged and there is a reduction in use for 1 month Early Active Treatment - Reduced use, working towards abstinence and improved well being. Late Active Treatment - Acknowledges SA as a problems, achieves abstinence and manages symptoms < 6 months. Relapse Prevention - Acknowledges SA as a problems, achieves abstinence and manages symptoms for at least 6 months. *Drake, R.E., Dartmouth-New Hampshire Psychiatric Research Center

16. Recommendations & Resourcesfor Treatment Stage specific treatment recommendations: General treatment Issues for DD population –Stabilization of acute symptoms followed by housing, establishing a working alliance, counseling and psycho-education needs, family issues, practical help and benefits, medication coordination. Substance Abuse resources APRA Mental Health resources CPEP Community Support Agencies

17. Stage Specific Treatment Recommendations* Stabilization Hospitalization, Detox, Incarceration, Crisis Houses, ACT Teams, Civil Commitment Engagement Focus - Wet Housing Outreach, Support in community, What client wants, Initial exploration, Without contingency, Facilitate access, provide practical assistance Persuasion Focus - Damp Housing, Expect slips, Cognitive Behavioral, Focused, specific info, Involve family in tx, Improve standard of living, Help with cravings, detox. Active Treatment Focus - Dry Housing, Expect slips, Cognitive Behavioral, Focused, specific info, Involve family in tx, Improve standard of living, Help with cravings, detox Relapse Prevention More independent, Increase self-efficacy and self advocacy, Self-help, RP plans, Health, well-being, Repair burned bridges, Teach negotiation skills, recognition of early warning. *Mueser, K.T. and Drake, R.E.

18. Substance Abuse Resources APRA: Addiction Prevention and Recovery Administration Contact and Referral Information: 825 North Capitol Street, NE Washington, DC 20002 Telephone: (202) 442-9152 Hours of Operation: 8:30 am - 5:30 pm http://app.doh.dc.gov/about/index_apr.shtm 24 Hour Hotline: 1(888) 7WE-HELP A special thank you to Bonita Bantom, LICSW for taking the time to come to Community Connections to train us on services offered by APRA and the referral process.

19. APRA • APRA is DC’s single state agency on substance abuse prevention and treatment. Under the Department of Health, it is the primary provider of substance abuse services for insured and uninsured DC residents. • APRA conceptualizes Substance Abuse disorders as “biopsychosocial” in nature and gears it’s services to meet the needs of the whole person. • APRA’s role in DC includes: • Planning & implementing the City-Wide Comp Substance Abuse Strategy. • Managing community based Primary & Secondary prevention programs. • Providing a comprehensive array of treatmentservices. • Administers standard of care certification requirement for providers.

20. Aftercare Assessments and Referrals Certification Detoxification Services Drug Treatment Choice Program Employment Services (APEX) Outpatient Services Prevention and Youth Treatment Services Primary Medical Care Project Orion Residential Services Special Population Services Special Services for Persons with HIV/AIDS Special Services for Latinos Special Services for LBGT Community Special Services for Mental Health Special Services for Seniors Special Services for Women with Children Spiritual Faith Groups 12-Step Meeting Information APRA: Innovative Treatment Initiatives:

21. Mental Health Resources Department of Mental Health (DMH)* Services: • Adult Forensics • Child & Family Therapy • Comprehensive Psychiatric Emergency Program • Educational Services   • Homeless Services • Individual & Group Therapy • Infants, Toddlers, & Parents • Multicultural Services • Organizational Development • Mental Health Rehabilitation Services * http://dmh.dc.gov/dmh/site/default.asp

22. MHRS Services • Crisis & Emergency • 24 Hour Access Helpline (1-888-7WE-HELP) Crisis and Emergency • CPEP • Crisis Houses – Jordan House and Crossing Place • Community Support • 11 Core Services Agencies – Cal AHL for referral. • Day Services/Intensive Day Services • Life Stride - (202) 635-2320 • McClendon Center - (202) 737-6191 • PSI - (202) 547-3870 • Community Based Intervention (CBI) • Youth Villages- (865) 560-2548 • Home First Care -(202) 737-2554 • Beyond Behaviors -(703) 658-9300 • Family Preservation Services - (202) 543-0387 • Assertive Community Treatment (ACT) • DCCSA - (202) 671-4010 • Pathways to Housing -(202) 393-5611 • Psychotherapeutic Outreach Services -(202) 588-9540

23. Community Connections Community Connections is a Core Service Agency located in SE Washington DC. It employs approximately 300 staff members and serves 2000 consumers. • Integrated intakes are completed daily by licensed clinicians. • Consumers are assigned to one of the following specialty teams • Trauma • HIV/Wellness • Recovery • Forensic • Dual Disorder • Children/Adolescents • Additional Services: • Psychiatric Clinic • Day Services and Community Support Groups • Psychotherapy Clinic • Supported Employment • Benefits Specialist • Multiple Research Projects

24. Outcomes • 6 intake staff trained on integrated assessment of dual disorders. • 300 integrated assessment completed since September 1, 2006. • Overall increase in awareness across agency about DD issues. • 100% more accurate case assignment. • Improvement in frequency and timeliness of referrals to detox and other APRA services.

25. Community Connections Intake Department