Report on Co-Occurring Disorders to California Mental Health Planning Council

1. Report on Co-Occurring Disordersto CaliforniaMental Health Planning Council David Pating, MD 10.15.2009

2. Overview • Update MHSOAC • Report on Co-occurring Disorders to MHSOAC • Status: COD treatment in California

3. Mental Health Services Act • Prop 63 – passed 2004 by 54% electorate • 1% assessment on incomes >$1M specifically to Transform Mental Health Care in California • Priorities: • Client & Family Centered • Cultural & Linguistically Competent • Recovery & Wellness Focused • Community Partnership • Integrated Service Experience • (Co-Occurring Disorders 11/09)

4. MHSOAC Staff and Officer • Chair, Andrew Poat; Vice Chair, Larry Poaster • Committees: • Services: Pating, Gould • Finance: Poaster • Client & Family: Vega • Cultural Linguistic Competency: • Evaluation: Poaster, Van Horn

5. MHSOAC Annual Priorities • In April 2009, the MHSOAC committed to the following annual priorities… • To fund and execute all five MHSA programs • Define “Transformation” and articulate its vision. • Develop an integrated consistent approach to evaluate the results of the MHSA and facilitate the adoption of the best practices across the entire community-based mental health system. • Adopt an approach for significantly reducing forms of mental health stigma and resulting discrimination towards those at risk and of living with mental illness and their families • Further define the roles and responsibilities of the Commission (in light of AB5xxx)

7. MHSOAC Current Priorities • 1) Prudent Reserves: MHSOAC continues to anticipate decreased revenue due to economic down turn from $1.6B (2008-9) to $900M in 2010. Fiscal discussions are underway to develop policy on maintenance and use of prudent reserves to smooth fiscal volatility. • 2) Statewide PEI Projects: Guidelines are expected in December 2009 to implement 3 statewide projects: Student Mental Health Initiative, Stigma and Discrimination Reduction, Suicide Prevention. Alternative funding mechanisms have emerged to create collaborative entities to administer these programs. • 3) Complaint Processes: DMH, in collaboration with MHSOAC is developing a comprehensive complaint review process that integrates county and state review.

8. Report on Co-Occurring DisordersTransforming the Mental Health SystemThrough Integration 9.25.2008

9. To Achieve the Promise… “To achieve the promise of community living for everyone, new service delivery patterns and incentives must ensure that every American has easy and continuous access to the most current treatments and best support services.” -Presidents New Freedom Commission on Mental Health (2003)

10. “Health care for general, mental, and substance-use problems and illnesses must be delivered with an understandingof the inherent interactions between the mind/brain and the rest of the body.”--The Institute of Medicine, 2006 To Achieve the Promise…

11. OAC Workgroup On COD • Recommendations to Improve Treatment for Co-Occurring Disorders • Template for Integrating Services under the Mental Health Services Act Following 6 months of hearings, the OAC Workgroup on Co-occurring Disorders Proposed in September 2008:

12. Transforming Mental Health “If we want people with co-occurring disorders to recover, we must promote systemic recovery.” -COD Report, p.2

13. Co-occurring Disorders: Report Overview • Statement of MHSA Tenets • “Whatever it Takes” • “Integrated Services” • Key Findings • Global Concerns • Systemic Strengths • Core Recommendation • “Promote COD Competency”

14. 1. MHSA tenets include: • Effective services for people living with serious mental illnesses must include “whatever it takes” for recovery. • Services must be “integrated.”

15. “Whatever it takes” • Refers, in part, to flexible funding. • Flexible funding allows the use of funds for a wide array of clinical services and supports beyond what is normally allowed in categorical funding.

16. “Integrated Services” • Means mental health prevention and treatment are coordinated so that there is “no wrong door” to receiving care. • Services should be concurrently delivered by a coordinated team of caregivers, often sharing single sites.

17. 2a. Global Concerns 50% • Key Finding #1. Approximately one half of peoplewith a mental illness or a substance abuse disorder, also have the other condition. These individuals have a co-occurring disorder (COD).

18. Mental & Substance Use Disorder Epidemiology (Regier, Arch. Gen Psy, 1991)

19. Comorbidity in Public Sector Treatment • In public sector, 49% to 70% of the clients • have co-occurring mental health • and substance use disorders National Survey on Drug Use and Health: National Findings 2004

20. Mental Diagnosis by Service TypeSan Francisco County 1998-2004 N=224, recruited from MH and SA Svc Havassy, Am J Psychiatry, 161 (1), 139-145.

21. SUD Diagnosis by Service Type

22. 2a. Global Concerns underserved • Key Finding #2. Individuals with COD are among California’s most underserved. Up to 60% of individuals receiving treatment in our public sector mental health system have COD. Most do not receive integrated care.

23. Treatment Status for COD Respondents In 2004 NSDUH Sample National Survey on Drug Use and Health: National Findings 2004

24. Utilization of Mental Health Services All significantly different at p < .001.

25. Percentage of Participants Who Received SA Services * *** Results of chi square tests. * p< .05, *** p = .000

26. 2a. Global Concerns disabling • Key Finding #3 COD is pervasive and disabling. Individuals with COD have more relapses, hospitalizations, depression & suicide, violence, homelessness, arrests and incarcerations, HIV, trauma and school failure.

27. Why Dual Diagnosis? Alcoholic or Substance Dependent with Mental Health Impairment 2-4 times more likely to seek treatment than any single disorder. (Grant, NIDA Monographs, 1997)

28. 2a. Global Concerns expensive • Key Finding #4 Insufficient support for integrated COD treatment leads to a paucity of programs and skilled providers. Unable to access appropriate care, individuals with COD are disproportionately served in emergency rooms, jails, foster care and among the homeless at great financial and emotional cost.

29. California Treatment System COD County DMH/ADP Vet Adm Untreated University & Schools Non-Profit Outpatient Recovery Homes Hospitals Jails/Court Methadone Clinics Insured “COD impact our Whole Treatment System”

30. Warning: Hospital Closures

32. Warning: Jail Overcrowding • 16% Arrests related to MH or SA • In CA some counties, up to 50% incarcerations are meth-related.

33. Warning: Foster Care • 70% of youth in juvenile detention, foster care or group homes abuse alcohol or drugs • 60% have mental disorders.

34. Warning: Homelessness COMPARE: • Cost Homeless Care $61,000 annually • Cost for Supportive Housing $16,000

35. 2b. California’s Strengths COD • DMH & ADP Established the Co-Occurring Joint Action Council • Developed “COD State Action Plan” • Screen Tool, Universal Charts, Standards • COD Best Practices in (16) Counties • Multiple funding sources available. • Effective model Peer & Family Services

36. 2b. Effective National Models Improved Quality at Lower Cost! • MHSA Supportive Housing • MHSA Full-Service Partnerships • California SACPA (Prop 36) AOD Diversion • Bexar County (Texas) MH Diversion • Allegheny County (Penn) MH Court • California AOD SBIRT (San Diego) Just what the doctor ordered…

37. Decision: How do we Integrate Services? California’s Strengths DMH/ADP + National BP DMH ADP Support Existing COD State Plan Transformation Through MHSA

38. Change in Two Sizes i I Little Big Integration

39. Support COD State Plan • Leverage MHSA funds, where possible, to implement components of COD Plan. • Screening Tool • Universal Charting • Training and Technical Assistance • Standards and Outcomes DMH-ADP …Priority focus for Integrated Plans?

40. In a Transformed System… • Involve the Whole Community • Integrate the Whole System • Treat the Whole Person Integration Means:

41. To Transform a System… The Science of Transformation • Change Culture: The Process of Transformation should Mirror its Goals. • Effective Implementation: Policy bodies must work through its intermediaries. • Focus on Achievable Outcomes: Measurable Progress should be rewarded Consultants, Ken Minkoff & Chris Cline (SAMHSA)

42. Unique MHSA Opportunities In a Transformed System of Integrated Care through the Mental Health Services Act… • Culture of Partnership: Mental Health Services should be delivered in collaboration with non-mental health partnerships; mirroring the partnership with clients and families. • Support Systemic Integration: Policy, Guidelines and Technical Assistance would consistently support “whatever it takes” for counties and agencies to comprehensively integrate services. • Measure “Whole-person” Care: The client experience of service continuity and meaningful care would be the hallmark of successful service integration.

43. Towards Integrated Plans… • Mental Health Partnerships • Explore means to enhance our Community Planning Process. • System-wide Integration • Review Integrated Plans for Continuity among MHSA Programs (CSS, PEI, INN, WET) and opportunities for flexible funding. • Client-Centered Outcomes • Explore measures of “client-centered” satisfaction and “continuity of care.” …Forward to Integrated Plan Discussion

44. 3. Recommendation “The MHSOAC should promote Co-occurring Disorders Competency as a core value in implementation of the MHSA and this value should be reflected in the Commission’s Annual Strategic Plan.”

45. Analysis • “By adopting co-occurring disorders competency as a core-value, the MHSOAC provides policy direction which facilitates the achievement of 10 key goals necessary to improve the treatment of co-occurring disorders, as well as, transform the mental health system in California.”

46. Transformative Goals for the Mental Health Services Act Goal 1: Create a Culturally CompetentIntegrated System of CareGoal 2: Establish Systemic PartnershipsGoal 3: Encourage DMH and ADP CollaborationGoal 4: Provide Ample Training and Technical AssistanceGoal 5: Close Gaps in the Continuum of CareGoal 6: Expand Peer-basedWellness & Recovery ServicesGoal 7: Empower Families to Enhance RecoveryGoal 8: Effectively Treat TraumaGoal 9: Use Outcomes to Measure ProgressGoal 10: Provide Incentives to Promote Transformation

47. In a Co-Occurring Disorders Competent System…

48. In a Co-occurring Disorders Competent System… • Integrated Care: Mental Health Care in California will be provided through an integrated continuum of care. • Partnerships: Mental Health Care in California will reflect a public health perspective, which results in the development of collaborative partnerships. • Collaboration: DMH & ADP will support COJAC’s state plan. • Training: MHSA Training & Technical assistance will support ongoing workforce development and behavioral health competency. • Comprehensive Continuum: Services for mental illness and substance abuse will be comprehensive and promote seamless transition in and out of emergency services.

49. In a Co-occurring Disorders Competent System… • Peer-Based Recovery: Peers will be broadly involved in the continuum of care and provide peer-based wellness and recovery services. • Strengthen Families: Families will be engaged and assisted to support and sustain recovery. • Trauma Awareness: Competency to treat trauma will be promoted and valued in MHSA programs. • Measure Progress: Use evidence & appropriate outcomes. • Incentive Transformation: Encourage growth of the mental health system towards greater integration and co-occurring competency.

50. Next Steps for COD • Recommendation Approved 11/08 • Services Committee to prioritize Pating’s recommendations: • Implement Screen Tool • COD Standards of Care • Offender-based Treatment