Breaking Down Barriers: Providing Integrated Care for Individuals with Severe Mental Illness and Substance Use Disorder

1. Breaking Down Barriers: Providing Integrated Care for Individuals with Severe Mental Illness and Substance Use Disorders Ken Bachrach, Ph.D. Debbie Innes-Gomberg, Ph.D. Monica Weil, Psy.D. Martin Hernandez, MSW

2. The Mental Health Services Act • Proposition 63 Passed November, 2004 • Identifies 4 distinct age groups: Children 0 -15 Transition Age Youth 16-25 Adults 26-59 Older Adults 60 +

3. MHSA Philosophy • Goal is to transform the mental health system • An inclusive planning process • Fund or expand programs that use proven service models • Assure accountability by collecting data on outcomes • Do whatever it takes to support clients to achieve recovery

4. Components of MHSA • Planning • Community Services and Supports FSP and Systems Development • Prevention and Early Intervention • Capital Facilities and Technology • Workforce, Education and Training • Innovation

5. Full Service PartnershipsAdults Adults who are a severe mental illness and who are: • Homeless • In jail • Frequent users of psychiatric hospitals or ERs • In institutions (IMDs, State Hospitals) • Being cared for by families but in the absence of the family would be at risk of the above.

6. FSP ServicesWhatever it Takes • Individualized, comprehensive treatment and support focused on recovery • 1:15 maximum staff to client ratio • Multi-disciplinary daily team meetings • 24/7 availability for crises • Field-based service approach • Peer support services • Integrated COD services • Housing and employment assistance

7. Services Provided in Residential Drug and Alcohol Treatment • Assessment & Treatment Planning • Individual and Group Counseling • Addiction and Recovery Services • Social Services • Community Linkages • Discharge Planning

8. TREATMENT PLANNING PROCESS • INTAKE • Assess need for treatment • and determine level of care • Complete required forms Admit Patient Preliminary Treatment Plan within 24 hours • COMPLETE • ASSESSMENTS: • ASI • Psych Symptom Chklist • Family/SO • Nutritional Screening • History & Physical • Psychiatric INTEGRATED SUMMARY INITIAL CASE CONFERENCE COMPLETE TREATMENT PLAN TREATMENT PLAN UPDATE / PT PROGRESS REVIEW

9. Groups • Educational (Addiction Education) • Psychoeducational (Relapse Prevention) • Process (Recovery Issues; Men’s / Women’s Group)

10. Core Groups • Addiction Education • Family Education • Relapse Prevention • Self-Help Orientation • Recovery Issues • Multi-Family Group

11. Residential Electives • Stress Management • Spirituality Group • Depression Management • Trauma Group (separate for men & women) • Grief & Loss • Anger Management • Recreational Therapy / Leisure Education

12. Residential Drug Treatment Recipients • Often have a long history of substance abuse and documented severe and persistent psychiatric disorder • Often homeless or recently released from a psychiatric hospitalization • Unable to stop their substance use on an outpatient basis, but don’t meet criteria for a psychiatric hospitalization

13. Four-Quadrant Framework for COD High severity Source: NASMHPD, NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002 Less severemental disorder/more severe substanceabuse disorder More severemental disorder/more severe substanceabuse disorder Less severemental disorder/less severe substanceabuse disorder More severemental disorder/less severe substanceabuse disorder High severity Lowseverity

14. HIGH - HIGH LOW - 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 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 LOW - LOW HIGH - LOW 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 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 Service Delivery for COD Source: Ries, 2004

15. FSP & Concurrent Residential Drug Treatment • A model for integrated services • Provides a safe environment to address substance use and mental health symptoms and to create a joint treatment plan

16. The Pilot Study • Purpose – To identify promising practices supporting integrated services for clients with co-occurring disorders • What added value does the FSP team serve while an FSP client is in residential drug/alcohol treatment? • What are the unique roles of the FSP team and the residential team? • How do the teams work together best?

17. FSP Clinical Case Conferences • 2 weeks after an adult FSP enrollee enters residential drug/alcohol treatment, a clinical case conference will be initiated by the FSP program or the Service Area District Chief. • Clinical case conferences continue every 30 days until the client is discharged from the residential program.

18. Clinical Case Conference • Review treatment plan- client stage of recovery and intervention strategies • Identify unique services provided by FSP team and residential treatment team. • Ensure services are not duplicated

19. Case Example #1 • Mr. Vinnie Boom Botz • 52 year old Hispanic male who has been diagnosed with Schizoaffective Disorder and alcohol dependence. • Long history of ETOH dependence • Patient suffers from head injury as a result of sustaining a beating while intoxicated and homeless. • Due to patient’s Organic Brain Disorder, frequent relapse on alcohol and other substances of abuse – patient required stabilization on the residential unit.

20. Vinnie, Continued • Case consultation began immediately between FSP Case Manager, FSP clinician and residential clinician and counselor. • DMH was consulted as well • As a result, patient was given a neuropsychological testing battery and reports were written to advocate for patient to receive SSI. • Patient was approved for SSI.

21. Vinnie, Cont. • Patient is currently living in sober living • Patient attends community meetings • Patient continues with FSP case management and therapeutic services • Patient’s SSI payments are administered by a third party as he is unable to manage his own finances. • Patient is receiving dental and medical services

22. Vinnie, Cont. • Patient has a strong connection with residential unit and with treatment facility. • Auditory and visual hallucinations remain, but have decreased in both quality and quantity • He has been able to recognize that his hallucinations are not reality and respond more appropriately to them.

23. Case Example #2 • Mr. Jimmy Rodz • 27 year old Hispanic male diagnosed with Psychotic Disorder NOS and Poly-substance abuse and Methamphetamine Dependence • Has short but extensive history of abusing drugs • Prior to age 18, client had been doing well, enrolled in college, and wanted to be a peace officer. • Mother explained that she believes that the community they lived in (high drug use), possibly influenced his extensive drug use

24. Jimmy Cont. • Prior to FSP services, he was accepting sporadic mental health services due to client’s non-compliance with recommended treatment. • Client had numerous psychiatric hospitalizations while he was under the influence or coming down from using. • When enrolled into FSP services, program also enrolled and placed in a residential drug treatment facility. • Client responded well to the structured treatment and the Co-Occurring Disorder Treatment. • FSP Program held weekly team meeting at which client’s case was discussed, and bi-monthly meetings with residential drug treatment program and FSP treatment team.

25. Jimmy Cont. • Client graduated residential drug treatment and moved on to sober living. • He continues to received FSP services and has moved to independent living. • Client has strong relationship with substance abuse support groups in the community. • Currently, client has full-time employment and is planning to enroll in college. Client continues to remain sober since entering FSP Program and Residential Drug Treatment.

26. Lessons Learned • It is important to have available short-term residential drug treatment in the continuum of care for individuals with severe mental illness and severe substance abuse problems • Short-term residential drug treatment can provide the opportunity to conduct a thorough assessment of the individual’s psychiatric and psychosocial functioning when not using substances that is rarely possible on an outpatient basis.

27. Lessons Learned • Mental health services can be initiated or continued in an environment where their effectiveness can be better evaluated, given the controlled environment of residential care • Mental health services can be coordinated during treatment and continued after leaving residential care in a seamless fashion • Frequent communication between AOD and DMH providers is critical to provide coordinated and integrated care.

28. Next Steps • Expand the number of AOD providers who can work with FSP programs • Continue to refine and improve communication and coordination of care • Evaluate the effectiveness of providing residential AOD services in improving outcomes