Community, Collaboration, Coalitions…Connections to Concurrent Disorders & Harm Reductions

1. Community, Collaboration, Coalitions…Connections to Concurrent Disorders & Harm Reductions What’s the Harm?: Harm Reduction Forum Allison Potts, MSW, RSW Concurrent Disorders System Integration Consultant Pinewood Centre, Lakeridge Health

2. Welcome • Who is here? • Why does this matter? • Who should it matter to? Allison Potts, March 2009

3. Concurrent Disorders and Harm Reduction: Community Issues? • Community? • Service providers and service consumers • The broad community – all citizens • System? • Addictions & Mental Health (youth & adult) • Hospitals • Police • Health and Social Services Departments • School Boards • Shelter/Housing Support System • Mutual Aid organizations • Community Health Centres • And on, and on Allison Potts, March 2009

4. Other Terms You May Hear for CD • Dual Diagnosis – popular in American literature, but in Canada refers to a Mental Health disorder and a developmental disorder – obvious limits are being increasingly recognized • Co-Occurring Disorders – commonly accepted term internationally for CD Allison Potts, March 2009

5. What About CD and HIV/HCV? • Triple Diagnoses is a term being used to describe the co-occurrence of substance abuse, mental health concerns and HIV/HCV Allison Potts, March 2009

6. What are these things? Allison Potts, March 2009

7. How is this working for us? HIV/AIDS Housing Med Add. $ MH Allison Potts, March 2009

8. The Outcome of Silo Work? • Compounded feelings of stigma (living with a mental illness, HIV+, substance use, and… • Unclear/Competing understanding or perspectives of the “primary problem” • Lack of coordination in service response and transitions • The burden of repeatedly sharing your story – and feeling the need to fragment it to meet system criteria Allison Potts, March 2009

9. A Perspective on Harm Reduction • Harm: physical or mental damage • Reduction: The Act or Process of Reducing • Harm Reduction: health promotion, prevention, assessment and intervention options that aim to decrease the health and socio-economic consequences of substance use and other high risk behaviours, without requiring abstinence. Abstinence-based strategies are an integral component of comprehensive harm reduction. Allison Potts, March 2009

10. Consider… • The numbers range from 10 – 50 % of individuals receiving care for HIV who also have concurrent mental health and substance use concerns • Screening recommendations may provide more accurate impressions as we move into more universal screening Allison Potts, March 2009

11. Access To Treatment • Research comparing treatment of patients with a depressive disorder and coexisting substance use issue found that they experience greater complexity of psychosocial needs and clinical presentation than those diagnosed with depression alone and they have fewer admissions and shorter lengths of stay. Brems et al 2006, Journal Of Dual Diagnosis (Research conducted in Alaska Psychiatric Institute). • Access to medical care, and clarity regarding HIV status is also impacted by this • The difficulty for research to be done on complex samples (aka people with more than one presenting issue) has impacted the availability of data supporting evidence based practices for individuals with CD Allison Potts, March 2009

12. Concurrent Disorders are an Expectation, not an Exception. This expectation must be incorporated in a welcoming manner into all clinical contact, to promote access to care and accurate identification of the population Dr. K. Minkoff

13. Evidenced Based Practices for CD • The most consistent finding across recent studies is that integrated treatment programs are highly effective • Ideally, integrated treatment means that the clinician weaves the treatment interventions into one coherent package • Several outpatient and residential studies also support the use of Stage-Wise treatments (based on the Transtheoretical Model of Change – Prochaska & DiClemente 1984), Engagement Techniques and Motivational Counselling Techniques Drake, R., Mueser, K., Brunette, M., & McHugo, G. 2004 Allison Potts, March 2009

14. Considering a Model for Community Change Allison Potts, March 2009

15. An Example of A Coordinated Community Response • “Think tanks” held with over 40 agencies represented to discuss CD • May 2005 - First focused on identifying the issue and getting “buy-in” to the need to develop a coordinated response • Second session narrowed to reflect commonalities in the various represented systems and set direction for next steps • Achieved agreement through all parties that a “Network” approach would facilitate further development Allison Potts, March 2009

16. System Based – Structures, Procedures, Policies And Practices • Management adopting best practices • Recognize the value of Capacity building from a team level • Support consistent policy and procedures (eg.Welcoming, Collaborative Treatment models, opportunities for inclusion) Allison Potts, March 2009

17. First Steps In Establishing the Network • Establish a shared understanding of the issues and the role of the network in regard to those issues • Develop a workplan that reflects a series of “quick wins” and longer term focuses to establish • Completed an on-line “needs assessment” that lead to establishment of training subgroup and a series of educational sessions aimed at enhancing the capacity of front-line staff Allison Potts, March 2009

18. The Concurrent Disorders Network of Durham Region Key Goals Embedded in the Workplan: • Support Coordinated system and policy development within Durham Region; across agencies, sectors, and ministries and actively share information regarding this client population • Provide or support the provision of a forum for this client population • Enhance community/system capacity by coordinating educational opportunities • Support/enhance system development • Provide advice/recommendations with regard to provincial policy development • To facilitate Welcoming Strategies that will improve quality of care Allison Potts, March 2009

19. Consumer Involvement and Feedback • Active Advocacy on the CD Network • Difference between “representative” and advocate • Focus Group Research The Consumer Representative on the CD Network shares these priorities: • Reduce the Stigma and the Secrecy surrounding mental illness and substance use so that all aspects of the treatment system support long term recovery • Welcome those seeking treatment and treat each door of the system as “no wrong door” • More integration of services to ensure clients needs are appropriately treated, including long term support; and  community based case management services Allison Potts, March 2009

20. What is CD Capacity Building? • Enhancing and Developing Skills, Influencing Change in Organizational Structures, and a Commitment to Overall Health Improvement • Hawe et. al. 2000 • Addressing the Gap between mental health and addictions treatment • Building on the strengths of current services and programs • Broadening the Base of treatment and increasing existing capacity Allison Potts, March 2009

21. What can be gained from increased CD Capacity? • Reduced Stigma • Improved treatment outcomes • Improved Screening & Identification • Better clinical coordination • Enhanced professional development for staff • Increased job satisfaction “A way to enhance a client’s treatment team” CD Capacity Building Team Member Allison Potts, March 2009

22. Components of CD Capacity Building • System based – structures, procedures, policies and practices (important to have top level “buy in”) • Resource level – redirection of $ • Clinician & Team based – support, information, resources and commitment • Partnerships & Collaboration • Development of Leadership Allison Potts, March 2009

23. Consensus Document and Charter • Asserts that the signing partners are agreeing to support and promote the implementation of a CCISC (Comprehensive, Continuous, Integrated System of Care) approach in the Durham Region • Planning directed at achieving a minimum of concurrent disorder capable services, incorporating evidenced-based practices across all components of the broader system • Signed by thirteen community organizations including: community hospitals, Regional Police Department, Youth serving organizations and community mental health organizations Allison Potts, March 2009

24. The Charter in Practical Terms • The Charter is based on Dr. K. Minkoff’s model • Welcoming • Evidence Based • Acknowledgement and Utilization of the Quadrant model • Policy Based • Consensus Based • Change directed to four areas: system, program, clinical practice, clinician Email me for a copy – apotts@lakeridgehealth.on.ca Allison Potts, March 2009

25. We Need To Do This Work! • Remarkable HIV-related biomedical advances have occurred in the last decade – most notably in medication management and monitoring symptoms – but access and adherence to these advances and thus, ability to benefit from, is less effective amongst disenfranchised individuals and particularly for those who lack support Allison Potts, March 2009

26. If this can be done…surely we can build a bridge between ideologies, systems, and professions! The Confederation Bridge Allison Potts, March 2009

27. Issues to Resolve • Mandates – recognizing natural “cross-overs” and historical omissions • Viewpoints of “different” models – getting away from the “versus” concept – abstinence vs. HR, genetic vs. learned behaviours, medication vs. therapy • Assumptions about philosophies and based in philosophies -misunderstandings, historical biases • Definitions and Language – gaining clarity of meaning • Education – learning from Eachother and respecting varied experiences Allison Potts, March 2009

28. Getting Started? • Sitting at the same tables • Exploring the Reception individuals receive in our System and the impact this has on Care and service delivery • Considering opportunities for collaboration and advocacy – the “quick wins” and what we can learn from them Allison Potts, March 2009

29. What can hold growth back? • Working in Silos • “Ownership” – of information, of clients • Stigma • Perceptions, lack of information, need for co-training • Fear (for jobs, for funding, of personal and agency limitations) Allison Potts, March 2009

30. Ongoing and Next Steps for CD • Living the process – being aware of small steps of change • Bridging the knowing – doing gap • Acknowledging and implementing welcoming practices • CD Capacity Building Team continuing to grow • Development of Training Modules – Shared Core Competencies and beyond – with focus on Charter organizations • Increased consumer feedback and representation on CD Network • Ongoing support of use of screening tools in agencies the region • Development of enhanced linkages with other community groups/coalitions Allison Potts, March 2009

31. References • Bouis, Stephanie, et.al. An Integrated, Multidimensional Treatment Model for Individuals Living with HIV, Mental Illness, and Substance Abuse, Health and Social Work, 32:4, November 2007: 268 – 278. • Boyle, P. and Kroon, H. Integrated Dual Disorder TreatmentInternational Journal of Mental Health, 35, 2, Summer 2006: 70-88. • Brems, C. et al. Comparing Depressed Psychiatric Inpatients with and Without Coexisting Substance Use DisordersJournal of Dual Diagnosis, 2 (4), 2006, 71-78. • Drake, R., Meuser, K., Brunette M.,McHugo, G. A Review of Treatments for People with Severe Mental Illnesses and Co-Occurring Substance Use DisordersPsychiatric Rehabilitation Journal, 27-4, Spring 2004, 360-374. • Minkoff, K and Cline, C. Changing the World: The Design and Implementation of Comprehensive Continuous Integrated Systems of Care for Individuals with Co-occurring Disorders. Psychiatric Clinics of North America, 27 (4):727-43, 2004 • Tsanos, A. and Herie, M. A Concurrent Disorders Capacity Bulding Initiative in a Clinical Program for People with Schizophrenia, in Skinner, W. Treating Concurrent Disorders: A Guide for Counsellors Ch. 16. CAMH 2005 • Sealy, John R. Dual and Triple Diagnoses: Addictions, Mental Illness, and HIV Infection Guidelines for Outpatient TherapistsSexual Addiction & Compulsivity, 6:195-219, 1999. • Stoff, D.M., Mitnick, L, & Kalichman, S. Research Issues in the Multiple Diagnoses of HIV/AIS, Mental Illness and Substance AbuseAIDS Care, 2004; 16 (Supplement 1): S1 – S5. • Whetten, K. et.al. Improving Health Outcomes Among Individuals with HIV, Mental Illness, and Substance Use Disorders in the Southeast AIDS Care, 2006; 18 (Supplement 1): S18-S26. • Panel on Antiretroviral Guidelines for Adult and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. January 29, 2008; 1-128. Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed March 25, 2008

32. Thank you! Contact Information apotts@lakeridgehealth.on.ca -for slides -for information, presentations, consultations Allison Potts, March 2009