foundations associates: expansion and enhancement grant ......including relapse prevention, trauma...

Expansion & Enhancement of an Integrated Outpatient Treatment Program Foundations Associates

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Foundations Associates:

Expansion and Enhancement Grant: Outpatient Program

Contract Information

DATES OF SERVICE: October 1, 2001 through September 30, 2004

GRANTEE FEDERAL IDENTIFICATION NUMBER: T1-12720 PROJECT NAME: Expansion and Enhancement of Davidson County Dual

Diagnosis Service Capabilities

PRINCIPAL INVESTIGATOR: Scott Orman

PROJECT LOCATION: Foundations Associates; Nashville, Tennessee

Dual Diagnosis Management; Nashville, Tennessee

Michael Cartwright, Executive Director

Project Purpose Foundations Associates (FA) responded to Davidson County, TN’s growing service needs for

integrated front end delivery services for adults with co-occurring disorders by embarking on a

three year expansion and enhancement project based on its existing outpatient program. The

purpose of the expansion component was to increase the capacity of FA’s American Society of

Addiction Medicine Patient Placement Criteria (ASAM PPC)-2 Level II.1 from 14 to 28 step-

down and case management services slots. This represents a 100% program expansion, creating

ASAM PPC-2 Level I outpatient services to accommodate 92 consumers annually. The purpose

of the enhancement component was to modify FA’s existing outpatient program by replicating

and adopting principle components based upon empirically supported findings from its

residential model. FA’s intensive outpatient program alternative conscientiously responded to

economic trends toward less restrictive, less costly and more responsive integrated community-

based treatment. The Intensive Outpatient Program (IOP) fills a niche between traditional


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outpatient psychotherapy and residential programs and demonstrates a commitment to managed

care objectives.

Over the three year time span, data were collected on FA’s newly designed Intensive Outpatient

Program (IOP) and FA’s existing residential program. The stated goal of the project was to

develop the least restrictive and resource intensive model of community-based dual diagnosis

treatment, while yielding results comparable to those of FA’s residential model. The purpose of

the present study was to compare longer-term, more intensive community-based services with

sustained follow-ups to FA’s highly acclaimed residential program. The purpose of this

comparison was to determine if the intensive outpatient services would produce comparable

efficacy results as the residential program. Project enhancement goals included, but were not

limited to, increasing periods of sobriety and behavioral stability, as evidenced through measures

of reduced recidivism, decreased substance use/harm reduction, and enhanced familial and

proximal natural and agency supports. In addition, we proposed to enhance key areas of service

gaps currently missing in outpatient treatment models of integrated care by raising the scope and

duration of service intensity to mirror that of the residential program.


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TABLE OF CONTENTS

FOUNDATIONS ASSOCIATES: .................................................................................................................................... 1

EXPANSION AND ENHANCEMENT GRANT: OUTPATIENT PROGRAM ..................................................... 1

CONTRACT INFORMATION................................................................................................................................................ 1

PROJECT PURPOSE........................................................................................................................................................ 1

BACKGROUND/PROJECT IMPLEMENTATION - YEAR ONE............................................................................................... 4 OPERATIONAL PHASE – YEAR TWO ................................................................................................................................ 7 OPERATIONAL PHASE – YEAR THREE ........................................................................................................................... 10

PROGRAM DESCRIPTION.......................................................................................................................................... 12

ASSESSMENT................................................................................................................................................................... 12 PROGRAM ELEMENTS..................................................................................................................................................... 14

Operationalize ASAM PPC-2 Level II.1 ................................................................................................................. 14 Created ASAM PPC-2 Level I.................................................................................................................................. 15 Integrated Case Management .................................................................................................................................. 15 Individual and Group Therapy ................................................................................................................................ 15 Family Education Training Program...................................................................................................................... 16 Long Term Perspective............................................................................................................................................. 16

PRINCIPLES AND COURSE OF TREATMENT .................................................................................................................... 18

EVALUATION ................................................................................................................................................................. 22

EVALUATION DESIGN ............................................................................................................................................. 22 SUMMARY OF BASELINE FINDINGS ............................................................................................................................... 23

Severity of Substance Use ........................................................................................................................................ 23 Psychiatric Severity .................................................................................................................................................. 26 Associated Problems – Medical, Family/Social, Economic, Housing, and Legal Problems .............................. 28 Service Utilization .................................................................................................................................................... 30

PROGRAM OUTCOMES.................................................................................................................................................... 34 Substance Use Outcomes ......................................................................................................................................... 35 Psychiatric Outcomes............................................................................................................................................... 38 Medical Problems..................................................................................................................................................... 41 Quality of Life Outcomes.......................................................................................................................................... 44 Family/Social Outcomes .......................................................................................................................................... 44 Finances .................................................................................................................................................................... 46 Housing Outcomes.................................................................................................................................................... 48 Incarceration............................................................................................................................................................. 49 Service Utilization .................................................................................................................................................... 50

CONCLUSION ................................................................................................................................................................. 53


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Background/Project Implementation - Year One

In December 2001, FA received formal approval for the contract with Metro Health Department

to test the IOP model that adopted components from FA’s residential program. All project

positions were filled in less than 4 months after enrollment was opened - the most significant

accomplishment in staffing. Within 6 months of hire, all key clinical staff had received an

extensive orientation on integrated care philosophy, DiClemente’s stages of change Trans-

theoretical model, crisis intervention, supportive therapy, substance abuse counseling skills,

medication monitoring, and family outreach. FA implemented ongoing (weekly) training

sessions that were often lead by national experts, and continued throughout the life of the grant.

FA’s commitment to training and education was demonstrated through the completions of

training modules to be used as consumer workbooks. FA’s first training module, Relapse

Prevention, was completed within 6 months of program start date with another three consumer

workbooks following the next quarter.

In keeping with proposed grant objectives, Foundations Associates revised existing outpatient

curriculum to include integrated service methods, motivational interviewing, and gender issues

in recovery. Project goals exceeded capacity goals within the first quarter after program

implementation. To respond appropriately, FA started several additional Level I outpatient

groups, individual outpatient therapy services and two aftercare groups provided for program

graduates.

A summary of key events occurring during implementation and year one were as follows:

Staffing

All key clinical positions were filled. FA increased their utilization of student interns and trainees to increase capacity for low cost

service provision.

Administrative

The grant received formal approval in December 2001 on the contract between Metro Health Department and FA.

FA relocated to Metro Center to accommodate grant expansion and enhancement objectives (March, 2002).

Program implementation began with the first GPRA baseline assessments on March 11, 2002.

Completed and implemented follow-up tracking database to better assist research and evaluation objectives.

Revised clinical curriculum for outpatient groups, which served as FA’s integrated IOP model.

Regular meetings were held between the University of Tennessee and FA, to conduct


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collaborative analysis of preliminary evaluation findings for eventual write-up and dissemination in scholarly publications.

In response to formative evaluation findings showing a loss of some consumers between intake assessment and treatment services, intake department intensified their efforts to facilitate engagement and seamless transition into services.

Treatment

Intensive Outpatient Services filled four groups to capacity. FA’s services expanded beyond the original scope of the grant. In response, FA started

several additional Level I outpatient groups, meeting one time per week. Additional expansion efforts included limited individual outpatient therapy services and two

aftercare groups provided for program graduates (one for women only).

Education & Training

All new project staff participated in a comprehensive structured orientation program. Presented, with CSAT evaluators, preliminary COFD cluster data findings at the 2002 MISA

conference in Lancaster, PA. Foundations Associates hosted two National Conferences on Co-Occurring Disorders in

Baltimore, MD and the second in Las Vegas, NV. A comprehensive training program was developed to provide ongoing (weekly) professional

development opportunities for outpatient staff.

Evaluation

Developed an auditing process with program intake staff to ensure timely and accurate GPRA data collection.

Organized an Advisory Council responsible for generating recommendations that will be incorporated into program development and quality improvement.

Intake GPRA data was collected on all 243 consumers admitted to TCE services. 16 follow-up assessments were completed on 19 consumers who completed their follow-up window, for a 6-month follow-up percentage of 84%. No 12-month assessments were due and FA’s overall follow-up percentage at the end of the first year was 84%.

Marketing/Sustainability

Completion of a training module for relapse prevention and medication management. Grants were submitted to enhance FA’s Vocational Rehabilitation services and SAMHSA

Jail Diversion grant to expand FA’s Memphis operations. Efforts made to expand FA’s partnerships with private insurance vendors to further diversify

and strengthen funding streams as well as increase community awareness of our services for dually diagnosed consumers for referral purposes.

Foundations Associates established an agreement with Maxwell Pharmacy to provide free medication on an interim basis for indigent consumers until they are connected with TennCare (Medicaid).

Challenges

Due to the larger-than-anticipated number of consumers served, we struggled to keep up with


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the large numbers of consumers requiring research follow-up. Despite the number of follow-ups due, we managed to meet our 80% follow-up criterion.

FA improved reimbursement success with TennCare (Medicaid) by improving our management information systems to ensure that all services were clearly documented for admissions and continued stay reviews.


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Operational Phase – Year Two

In year two, FA’s major activities were tracking grant services for quality improvement, and

refining program infrastructure to ensure GPRA intake and follow-up data collection were timely

and accurate. A major accomplishment in year two of the grant was the completion,

implementation, and marketing efforts around eight workbook modules developed and used by

FA’s staff and consumers. FA’s commitment to education and training was evident through their

comprehensive training program that provided weekly professional development opportunities

for outpatient staff as well as the establishment of bi-weekly leadership team meetings allowing

management to develop more collaboration and mutual support among outpatient staff.

Within year two of the grant, FA completed and implemented a comprehensive Management

Information System (MIS) that supported data collection for research and streamlined clinical

information management. The comprehensive MIS project included elements that supported

staff credentialing/training, intake/GPRA collection, treatment planning, service delivery, and

billing.

Specific key activities occurring during the second year of operations were as follows:

Staffing

Dr. Lisa Webb-Robbins was hired as the Director of Research and Development for Dual Diagnosis Management.

Dr. Grich, Clinical Psychologist, transitioned to a full time clinical position to provide ongoing quality staff training and assist in supervising clinical staff under the Clinical Director.

FA’s Vocational Rehabilitation services added an additional staff to meet the demands of participating consumers.

Administrative

FA was more than 70% of the way toward stated goals of 500 program participants, with the expectation of exceeding the goal of 500 participants by a substantial margin.

FA implemented an agency wide Quality Assurance Committee to meet on a monthly basis, to address administrative issues concerning the AdvoCare SSOC Audit and other administrative issues as needed.

Received credentialing approval on all case managers from AdvoCare. FA implemented a monitoring tool to improve tracking vocational rehabilitation referrals and

job placement contracts. A Cultural Competency Committee was formulated to address diversity issues within the

agency. The committee circulated and reported on a cultural competency survey. Spanish translations of agency literature were made available upon request.


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Treatment

FA operated five IOP groups throughout the day. Two at 9:00am, one at 12:30pm, one at 2:30 pm, and another at 5:30pm to accommodate all consumer needs. This more than doubled capacity projections outlined in the original TCE grant application (which proposed a total of two groups).

Specialty outpatient groups were created through a series of focus groups with both consumers and providers identifying unmet community needs. Five groups started July 2003, including Relapse Prevention, Trauma Recovery, Spirituality, Relationships, and Healthy Living.

Additional expansion efforts included limited individual and couples outpatient therapy services and two aftercare groups provided for program graduates (one for women only).


FA completed eight modules of an outpatient clinical curriculum. This curriculum served as the basis for FA’s integrated IOP model.

Evaluation staff attended GPRA software training presented by ACS/Birch & Davis in Washington, DC and in Alexandria, VA.

FA held its 4th Annual Conference on Co-Occurring Disorders in Nashville, TN. FA sponsored conferences in Orlando, FL and Arlington, VA on co-occurring disorders. FA collaborated with over 50 statewide A&D and MH providers, along with the DMHDD

and the Tennessee Department of Health, Bureau of A&D Services on the COSIG proposal. FA prepared the proposal on behalf of the statewide plan developed through the collaboration.

Agency representatives appeared on a local cable network to discuss co-occurring disorders and resources for services.

Evaluation

Intake GPRA data was collected on all consumers admitted to TCE services. FA continued to maintain an 85%-95% follow-up percentage despite the dramatic increase in

the number of participants served. 387 six-month follow-up assessments were completed on 440 consumers who completed

their follow-up window, for an overall 6-month follow-up percentage of 88% by September 2003.

210 twelve-month follow-up assessments were competed on 229 consumers who completed their follow-up window, for an overall 12-month follow-up percentage of 92% by September 2003.

Early COFD cluster data highlighted unexpected clinical issues. In particular, approximately 40% of consumers reported head injuries and 30% reported issues of chronic pain.


Aggressive TennCare (Medicaid) enrollment. Explored state bridge funds. Identified services being provided by grant funded, non-reimbursement staff, and worked

towards transitioning them to billable staff.


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Collaborated with the City of Memphis to apply for the Interagency Council on Homelessness application that will provide integrated ACT services to chronic homeless persons in Memphis in collaboration with other local agencies.

Challenges

One of FA’s challenges of year two was transitioning TCE funded services to other funding sources, such as Medicaid funds needed to provide services for Nashville’s indigent populations after the project ends September 2004.


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Operational Phase – Year Three

In the third and final year of project funding, key activities focused on final preparations for

continuing expanded outpatient services after September 30th. Preliminary evaluation analyses

were conducted to determine program efficacy and to provide leverage for finding additional

funding. Some agency reorganization continued so that all clinicians were billable under

Medicaid requirements by the end of this final year. Specific third year activities included the

following:

Staffing

New positions included a Marketing Director, Research Assistant, Medical Records Assistant, and a Vocational Case Manager.

Administrative

FA successfully completed a CARF (Commission for Accredited Rehabilitation Facilities) audit and was awarded a three-year CARF accreditation.

FA continued to transition project candidates to TennCare to prevent an interruption in their services as the end of the grant approached.

Treatment

FA continued to operate five IOP groups throughout the day, which more than doubles the capacity projections outlined in the original TCE application.

FA began to utilize motivational incentives to increase regular IOP attendance.


FA and Dual Diagnosis Recovery Network (DDRN) actively worked to promote national circulation of workbook modules through workshops, trainings and conferences.

Continued commitment to an extensive training program for all agency staff.

Evaluation

FA continued Quarterly Assurance Committee meetings with an activity focus on completing and recording consumer satisfaction surveys, as well as confidential employee satisfaction surveys.

Preliminary data indicated successful project services across all domains. Follow-up rates continued to exceed an 85% rate. Average IOP group attendance was 10 per group.


FA submitted a proposal to Robert Wood Johnson Foundation for “Paths to Recovery: Changing the Process of Care for Substance Abuse Treatment”.

Marketing Director developed marketing strategy to determine the demand of local services, services trends and worked closely across departments in program development and


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improvement. Marketing efforts were underway to promote FA’s program services to local area providers, hospitals, corrections facilities, and other applicable agencies.

Completion and circulation of four workbook modules. Workbooks are a regular part of FA’s IOP group program.

Challenges

Many of the preparations for the loss of program dollars at the end of the third year began in the second year of the project. Despite an early start, many of these challenges continued to be a major focus of project related activities. Fortunately, by the end of the final program year all FA clinical staff was fully credentialed largely due to extensive training efforts. FA’s new agency-wide MIS was also fully operational and consistently used by all agency staff, which greatly enhanced the agency’s ability to track all consumers and bill for services appropriately.


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Program Description As our interdisciplinary teams worked more effectively to address specific consumer needs

throughout the project, we moved well-beyond traditional service model programs and enhanced

integrated care principles to incorporate a holistic recovery-oriented program strategy. Treatment

integration and principle enhancement has been essential in responding to a multiple-needs

population, like that of the dually diagnosed. In the following subsections, we describe a

comprehensive assessment process, enhanced integrated case management and therapy

strategies, and a family education training program. The enhanced IOP strategies were designed

with long term perspectives to extend the duration of all services to the community-based

consumer to decrease long-term societal cost and improve clinical outcomes.

Assessment

Assessment constitutes the core of early intervention. Ongoing accurate assessment guides

treatment decisions, monitors changes over time, reveals new and additional service needs, and

allows for program evaluation and research. Assessment domains and procedures were routinely

examined in detail to allow clinicians and FA’s evaluation team to determine program efficacy.

One key aspect of FA’s assessment model is that primary assessment responsibility lies in the

hands of full-time clinical intake staff as opposed to alternative models that distribute intake

assessment responsibility across several staff that are primarily focused on other responsibilities.

The specialized approach serves to maintain a high level of consistency across assessment and

ensures that intake assessments are conducted by a clinician with experience assessing both the

severity of substance use and the extent and nature of co-morbid mental health conditions. The

intake responsibility was centralized to two admissions’ counselors who administered all core

assessment materials used for clinical evaluation (and research), generated summary reports, and

made appropriate referrals for other needed clinical assessments (e.g., psychiatrist, psychologist,

or other specialist).

A group of assessment tools were selected with established reliability and validity in populations

similar to that served by Foundations Associates, i.e., predominantly individuals with substance

dependency conditions and serious mood or thought disorders. The complete protocol included

both clinician-report and self-report items, in order to minimize the impact of biases on the part

of the clinician or the consumer. Accommodations were made as needed to the basic assessment

package, depending on the presenting needs of the consumer and with particular sensitivity to

diagnostic severity, reading level, special needs or disabilities, and cultural considerations.

Non-standardized protocols were developed to achieve two ends:


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Operationalize ASAM PPC-IIR measures to facilitate decision-making regarding placement.

This included application of the ASAM crosswalk and development of specific criteria that

defined medical necessity standards for each level of the FA continuum of care, and;

Provide depth to the psychiatric portion of the evaluation to offer a platform for integrating

treatment elements. This included an in depth interview regarding the consumer’s family of

origin, behavioral health and substance dependency treatment history, prior traumas,

behavioral trends, psychiatric symptomatology, and psychopharmacologic treatment history.

Assessment components included:

1) Prescreening (completed by referring agency or administrative staff)

Brief Referral Form with succinct diagnostic and treatment history

Motivational Readiness: Consumer completes the University of Rhode Island Change

Assessment (URICA; McConnaughy, Prochaska, & Velicer, 1983)

2) Intake Assessment

Comprehensive Psychosocial Interview: treatment history; multiaxial DSM-IV

diagnostic assessment; mental status examination; assessment of contributing factors,

including: social/family/peer concerns, legal, cultural, spiritual, vocational, housing,

abuse, and other consumer-specific issues; information from collateral informants;

Release of Information; eligibility for public assistance.

Standardized assessment battery: Selected Addiction Severity Index (ASI) items

(Alcohol/Drug Use/Legal), Brief Symptom Inventory (BSI), Treatment Services

Review (TSR), COFD Assessment Scale, Triage Assessment for Addictive Disorders

(TAAD), Lehman’s Quality of Life (modified administration), University of Rhode

Island Change Assessment (URICA) and SF-12 Health Survey.

American Society of Addiction Medicine (ASAM) PPC-IIR Multidimensional

Assessment

Initial Treatment Planning Recommendations

3) Psychiatrist Assessment


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Psychiatric interview and review of previous assessment materials

Diagnostic Impressions (multi-axial DSM-IV)

Need for pharmacotherapy

Assessment of acute intoxication/withdrawal risk

Evaluation of co-morbid medical conditions

Review of Treatment Planning Recommendations

4) Psychologist or other Specialized Assessment (as needed)

Objective or Projective Psychological Testing

Laboratory Tests (Serum or Urine Toxicology)

Vocational Assessment

Nursing Assessment

Case Management Assessment; need for additional services

Referrals for additional assessment as needed

The assessment process was used to determine the consumer’s appropriateness for Foundations’

intensive outpatient program (IOP) or residential program. If a consumer was deemed a poor

match for Foundations’ IOP or residential program (due to a single diagnosis, poor fit with

individual treatment needs, or recommendation for another level of care), the appropriate referral

was expedited.

Program Elements

FA’s original outpatient model only addressed acute short-term stabilization with an average of 6

weeks in treatment, while residential consumers averaged 4 months in treatment. The residential

program offers a continuum of wrap around services including long-term case management,

psychopharmacologic treatment, vocational rehabilitation, intensive outpatient, individual and

group therapy, psychoeducation, and 12-step treatments and interventions, and a family

education program. FA’s community-based program was expanded to increase the capacity and

duration of front-end services by providing longer term, sustained follow-up community service

programs. The expanded IOP program elements were delivered in a less restrictive environment

but with the same service intensity seen in the residential program.

Operationalize ASAM PPC-2 Level II.1

FA designed the experimental IOP to include field tested, five days per week, three hours per day

intensive, integrated dual treatment program with three daily groups, each one hour in length,

designed to provide psychoeducation, addictions treatment, relapse prevention, therapy, and


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coping strategies. Cognitive therapy and motivational interview were integrated with a twelve-

step dual recovery intervention. Staff was trained to utilize DiClimente’s stage-wise approach

that addresses stages of change and defines treatment according to the individual’s readiness to

change. Psychiatric evaluation, medication management, individual psychotherapy, and case

management were also provided for all participants. Services were delivered by a

multidisciplinary team of professionals with dual treatment expertise, including psychiatrists,

psychologists, licensed clinical social workers, and certified alcohol and drug counselors.

Transportation was provided to all attending participants.

FA increased program capacity for front-end delivery services from 14 to 28 openings and

offered services to uninsured, homeless, and low-income individuals. Participating consumers

received Cognitive Therapy and Motivational Interviewing as part of the integrated twelve-step

dual recovery intervention approach.

Created ASAM PPC-2 Level I

FA provides a step-down phase of ASAM PPC-2 Level I treatment for residential consumers and

believes it efficacious for a community-based program. Therefore, FA created 92 openings for

individuals who completed the intensive Phase I of ASAM PPC-2 Level II.1 outpatient

treatment. The transitional services offered in the step-down residential program were expanded

to community-based recipients. The expanded services included case management and

individual/group therapy consistent with ASAM PPC-2 Level I criteria over an additional period

of 6 months following completion of Level II.1 services. The new services included one 1

hour session per week to three 2 hour sessions per week, offered additional concurrent,

scheduled individual therapy sessions. The new program design offered medium to long-term

wrap-around services utilizing a multidisciplinary specialist approach.

Integrated Case Management

Residential consumers receive extended case management, consisting of 4 months of ongoing

services by a multidisciplinary team comprised of a housing specialist, psychiatrist, psychiatric

nurse, and specialists in mental health and substance abuse. Community-based recipients, as part

of the expansion project, began to receive appropriate ongoing follow-up services analogous to

their specific treatment needs. Extended case management services for the community-based

recipient were identified as a critical component for the consumer who had achieved some

stability upon program completion, but continued to need ongoing case management.

Individual and Group Therapy

Prior to the expansion project community-based treatment opportunities in the Davidson County

area for individuals with co-occurring disorders were limited to 6 weeks of ASAM PPC-2 Level


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II.1 intensive day services and evening 12-step meetings. Following program completion, the

consumer returned to the same fragmented and uncoordinated service delivery system lacking

the social support needed to curb high recidivism and relapse rates. An essential element to the

community-based project was to extend Individual Therapy that would address consumer

privacy, offer flexibility, and allow consumer specific treatment and intervention approaches.

This component provided the consumer with an ongoing integrated delivery system that

continued throughout the individual’s highest at-risk periods following program completion.

Group work covered a wide variety of topics including psychoeducation, health education, life-

style issues, stress management, social skills training, occupational preparation, and recreational

pursuits. Group feedback included a sense of belonging for those with limited social support,

opportunities to improve and often develop interpersonal skills, and a rich source of ideas for

problem solving and coping skills. By providing extended therapy, beyond program completion,

present research findings show a significant decrease in overall societal cost as well as an

improved quality of life for program participants.

Family Education Training Program

Research has shown that families and friends play an important role in a consumer’s recovery,

community reintegration and pharmacologic compliance. FA developed and implemented a

family training program both in the community-based and residential treatment. The family

training program provides intensive psychodynamic training and educational curriculum,

conducted evenings and weekends, beginning the final two weeks of the individual’s

participation in Level II.1 services. Modules included diagnostic education, evaluation of the

impact of co-occurring conditions, psychopharmacologic education, assessment of Family

dynamics, and principles of treatment and healthy/non-enabling interactions. The Family

training program strengthens the individual’s support system prior to the individual’s return to

that system.

Within both models, FA’s field tested enhancement components of intensive family/natural

support training and educational program and wrap around services were added to address gaps

in treatment for both residential and outpatient consumers, as well as early prevention efforts for

the children of dually diagnosed parents. The family education training and intervention program

is a product of consumer in-put.

Long Term Perspective

The IOP program was designed, under current project objectives, as a time-limited and

structured treatment approach following completion of a community-based program. The

enhanced IOP program offers extended therapeutically coordinated clinical services in a stable

treatment setting. By replicating empirically supported elements of the residential program and


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adopting those same components in an extended IOP program, FA expects to minimize the need

for inpatient psychiatric and/or substance abuse treatment, and decrease recidivism and relapse

rates while improving pharmacological compliance. Besides extending the duration of overall

services for community-based consumers and thereby improving clinical outcomes and their

quality of life, FA anticipates a significant decrease in long-term societal costs associated with

relapse and decompensation cycles of dually diagnosed individuals.

FA’s efforts for funding sustainability included the acquisition of a TennCare (Medicaid)

contract for selected case management services, and in Year Two of the grant, FA negotiated

expansion of services to AdvoCare by including ASAM PPC 2R Level I Outpatient treatments.

FA further secured a service contract for vocational services with the Department of

Rehabilitation to provide Job Placement Services for Alcohol and Drug, Job Placement for

Mental Health and Supported Employment for Mental Health. In addition, Vocational

Rehabilitation Services provided were billable under FA’s case management contracts.

Commitment to education and funding sustainability are united in FA’s annual conferences held

several times a year throughout the United States with the focused purpose of educating

providers, policy makers, law enforcement, consumers and their families on co-occurring

disorders and related issues.

A long-term, well established philosophy of FA is to continue utilizing consumer feedback via

satisfaction surveys and focus groups, as well as staff in-put regarding program development.

FA’s clinical staff worked closely with evaluation staff to ensure quality of service and identify

opportunities for program improvement obtained through scientific inquiry.


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Principles and Course of Treatment

Foundations Associates’ residential program attained model project status for integrated

treatment by SAMHSA as one of three exemplary programs in the United States featured at the

Co-occurring Institute of the SSDP V (State System Development Program 5th) Conference, and

the residential services were selected as a finalist for the American Psychiatric Associations’

(APA) Gold Achievement Award. Foundations Associates applied its residential program

philosophy and services to its expanded and enhanced IOP program with the expectation of

improving IOP clinical outcomes and decreasing long-term societal cost. FA’s goal for the

outpatient program’s continuum of care and service intensity philosophy was to reduce

decompensation/relapse and associated cost through emulating elements of its highly successful

residential program. The IOP program premise is based upon key elements best described by

Minkoff (Minkoff, 2000) as the seven principles inherent in an integrated model of care:

1. Comorbidity is an expectation, not an exception.

Based upon the 4-quadrant subtyping of disorders, Foundations Associates has historically

served the high severity SPMI/substance dependency population, with the majority of consumers

having experienced multiple psychiatric and substance dependency treatment episodes prior to

admission. An enhanced and expanded IOP continuum of services was designed to address

integrated care across all service levels, including case management, therapeutic interventions,

12-step approaches (i.e., application of a dual recovery model), and psychopharmacologic

treatment. Recruitment of staff trained in integrated theories proves to be a challenge. Hence,

staff training, workshops, conferences, and educational forums are encouraged for all staff to

broaden their experience in integrated treatment. Likewise, staff members rotated presentations

in weekly meetings on contemporary treatment approaches to integrated care. As part of the Dual

Diagnosis Recovery Network (DDRN), a library that serves as a national repository of dual

diagnosis research, information is available onsite to all staff.

2. Successful treatment requires most importantly the creation of welcoming, empathetic, hopeful, continuous treatment relationships, in which integrated treatment and coordination of care are sustained through multiple treatment episodes.

All program elements are directed toward emphasizing staff/client relationships in an engaging,

non-punitive atmosphere. From the initial assessment information, a plan of care is established

that views both disorders as co-primary, addresses dual recovery, and is based upon the

individual’s readiness to change. Staff is directed not to impose traditional treatment goals, rather

to establish client driven plans of care. Relapse and decompensation are viewed as characteristic

of the pathology of the conditions and efforts are aggressively directed to re-engaging the client


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when those events occur. These episodes are used to enhance consumer introspection regarding

triggers and symptoms of relapse and decompensation and are addressed through community

meetings, and individual therapy sessions.

Rather than relying on traditional approaches, efforts are made to develop resources that meet the

needs of the dually diagnosed consumers. Residential treatment is not always a realistic option

for many individuals with complex dually diagnosed disorders, so Foundations developed an

IOP program to address the diverse needs of the population. For example, its IOP program

provides an enhanced and expanded community based program that incorporates more

comprehensive treatment philosophies and strategies than traditional disease specific models.

3. Within the context of the continuous integrated treatment relationship, case management and caretaking must be balanced with empathetic detachment and confrontation in accordance with the individual’s level of functioning, disability and capacity for treatment adherence.

The balance between traditional normative mental health caretaking versus substance abuse

empathetic detachment is attained through individual plans of care that are developed through

the course of an aggressive treatment plan. Ongoing modification to plans of care occurs through

weekly team evaluation of the individual’s progress in treatment. Typically efforts during the

earlier phases of treatment are directed toward stabilizing psychiatric symptomatology and

managing withdrawal symptoms and associated cravings. Hence, typically the first two weeks

result in a higher level of staff case management and caretaking efforts. As stability progresses

the onus gradually shifts to responsibilities the consumer bears in directing the course of

treatment.

FA’s integrated services allow for the use of the most appropriate treatment for the consumer at

his or her particular level or time of need, in a non-restrictive environment. Thus, Foundations

integrative treatment plans are customized to meet both the mental health and addiction needs of

the patient.

4. When mental illness and substance disorder co-exist, both disorders should be considered primary, and integrated dual primary treatment is required.

Aggressive psychopharmacologic treatment and monitoring, applied in conjunction with

recovery principles such as sober, structured housing and DRA are essential to a co-primary

treatment approach. Given the severity of the population treated at Foundations Associates, we

quickly identified a need to extend the length of program participation outside of normative

single-diagnostic treatment periods. Instead, consumers are evaluated individually according to


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progress in the program, level of stability attained, and related characteristics before movement

to less restrictive care occurs.

Consumers enrolled in the IOP program are encouraged to attend 12-step meetings and

participation in aftercare programs. In the event of relapse or decompensation, interventions are

rapidly rallied either through intensive psychiatric evaluation and monitoring, relapse evaluation

committees and modifications to the individual’s therapeutic contract/treatment plan, or a

combination of both. When decompensation in one sphere occurs, attendant monitoring of the

other sphere is accordingly engaged.

5. Both psychiatric illnesses and substance dependence are examples of chronic, biological mental illness which can be understood using a disease and recovery model. Each disorder is characterized by parallel phases of recovery: acute stabilization, engagement and motivational enhancement, active treatment, and prolonged stabilization, rehabilitation and recovery.

Psychoeducation is a hallmark of this principle, in that education on the disease model,

management strategies, medications, self-monitoring, inter-relatedness of conditions, and the like

bring to bear the element of hope in recovery and facilitate movement through stages of change.

Psychoeducation occurs through structured group programs, house meetings, residential therapy

programs, family education programs, and use of a NAMI model, Bridges, which offers

consumer led in-house education groups. All psychoeducational groups integrate dual recovery

as a central theme, emphasizing methodologies for maximizing quality of life. In addition, a

significant majority of staff includes both individuals in recovery and graduated program

consumers.

Similarly, the impact of the community as a whole is significant in facilitating change. Peer

Mentors, community driven groups and committees, and a general theme of consumer

empowerment immeasurably emphasize recovery elements.

6. There is no single correct dual diagnosis intervention. Appropriate practice guidelines require that interventions must be individualized, according to the subtype of dual disorder, specific diagnosis of each disorder, phase of recovery/stage of change, and level of functional capability or disability.

The protocols discussed in the Assessment section of this document are used to define level and

extent of symptomatology, history of substance use, and readiness to change. These dimensions

direct the approach to treatment and clinical treatment matching with the model of intervention.

Again, the population treated at Foundations Associates predominantly consists of the 10% of


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the population using in excess of 70% of the healthcare resources. As such, the severity of the

conditions reinforce that movement through stages of change must occur at a pace directed by

the consumer. Typically early phases of treatment are directed at stability, medium phases at

defining personal goals and plans for attaining those goals, and later phases toward careful,

deliberate reintegration.

While the agency espouses an abstinence orientation, we recognize the psychopathology of the

population, the typical multiple episodes of treatment, and the importance of an effective harm

reduction model. Consumers not ready for an abstinence model are treated non-punitively and

efforts remain directed at addressing the individual’s motivation for change at whatever stage

s/he is currently prepared.

7. Within a managed-care system, any of the individualized phase-specific interventions can be applied at any level of care. Consequently, a separate multidimensional level of care assessment is required.

ASAM dimensions are applied at admission to attempt to match treatment/placement needs

within the system. Domains are operationalized to direct the plan of care by incorporating

various protocols that measure psychiatric symptomatology, treatment history, and a

combination of other psychiatric and substance dependency measures. While reliance on self-

report information contains certain faults in data gathering, it permits a measure of the

consumer’s perception of need for treatment. That perception is the basis for defining a client

driven plan of care that cannot be discounted.


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Evaluation

EVALUATION DESIGN

The overall research plan was to assess each consumer entering Foundations Associates’

enhanced and expanded integrated IOP in several key clinical, functional, and life domains, and

to closely follow each consumer over a three-year period. Within this framework, all consumers

entering FA were offered an opportunity to participate in the research model that repeats

administration of specific protocols at admission, and again at six and twelve months following

completion of the treatment program. The purpose of the outcome evaluation was to examine the

impact of the outpatient program on consumer outcomes (e.g., substance use, psychiatric

symptoms, quality of life, medical status, and service utilization) through the use of a nested

longitudinal design. To minimize threats to internal validity, demographics, service utilization

and clinical histories were colleted and examined at baseline. Baseline assessment included a

comprehensive evaluation of major life domains and placement/service needs based upon the

American Society of Addiction Medicine Patient Placement Criteria for the Treatment of

Substance-Related Disorders (ASAM PPC-IIR) standards, evaluation of the individual’s

preparedness for services, and use of multiple sources of information to assess each outcome

domain. Each primary outcome domain comprised multiple measures based upon client self-

report, evaluator observations, and objective indicators. This approach had significant benefit

because it minimized bias resulting from relying too heavily upon any single source of

information, and it provides multiple indicators for use in latent variable analysis (a method

which relies on multiple measures to eliminate measurement error). At a global level, domains

and associated measures include:

Table 1 Measures

Domain Measures

Substance Abuse Addiction Severity Index (selected items) Government Performance and Results Act (GPRA) Report Form

Triage Assessment for Addictive Disorders (TAAD)

Mental Illness &

Physical Health

Brief Symptom Inventory SF-12 Health Survey

Co-Occurring & other Functional Disorders Assessment Scale (COFD)

Treatment Service Review (TSR)

Cost Effectiveness Measures of program costs

Measures of consumer service utilization cost

Quality of Life Lehman’s QOL (Modified Administration)

Consumer Satisfaction Client Satisfaction Questionnaire Motivation URICA Change Assessment Scale


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Summary of Baseline Findings

Severity of Substance Use

This report details data collected on 816 research participants in Foundations Associates

integrated treatment program for individuals with co-occurring disorders. Baseline findings for

clients entering Foundations Associates consistently show substantial substance use along with a

variety of symptoms typically associated with substance abuse and dependence.

Each participant was screened for alcohol and drug abuse or dependence using the TAAD

interview, which is designed to identify symptoms of a possible current DSM-IV diagnosis for

alcohol or other drugs. The TAAD has 16 items that address drug dependence and 19 that

address alcohol dependence. The instrument assesses both dependence and abuse by establishing

a pattern of behaviors or consequences rather than simply a pattern of use. According to TAAD

scoring procedures (Hoffman, 2001), possible dependence is indicated if the individual endorses

items from at least three of the DSM-IV categories for dependence. A more stringent dependence

criterion requires positive responses on at least five different dependence items. Similarly,

possible abuse is indicated if the individual endorses at least one item in any of the four DSM-IV

abuse categories while the more stringent abuse criteria require at least two different indications

of abuse in one or more of the categories. For our purposes, indications for abuse and

dependence reflect the more stringent criteria.

As illustrated in Figure 1 on the following page, many participants reported behaviors and

consequences indicative of multiple dependence and/or abuse patterns. More consumers reported

behaviors and consequences of drug dependence and abuse compared to alcohol dependence and

abuse. Far greater percentages met the criteria for possible dependence or abuse (see Figure 2),

which do not require selecting multiple items within each DSM-IV category.


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Figure 1

Figure 2


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As a supplement for the TAAD substance abuse/dependence measure, GPRA items are included

in this report to capture frequency of substance use in the 30 days prior to treatment. The results

can be seen in Figure 3 below. Again, illegal drug use (61.3%) was reported more often than any

use of alcohol (50.7%) or alcohol use to intoxication (38.2%). In terms of specific illegal drugs

reported, cocaine (43.4%) and marijuana (26.8%) use were reported more than all other illegal

drugs combined. It is somewhat surprising that cocaine use was reported more frequently than

alcohol use to intoxication. However, this trend is consistent with findings from the TAAD

assessment, which also indicated more drug abuse/dependence compared to alcohol.

Figure 3

While the TAAD instrument provides a more stable measure of substance use by focusing on

symptoms associated with dependence and abuse, it also limits our understanding of the severity

of substance use by type of substance. Figure 4 below details the frequency of substance use and

provides a more detailed indication of substance use severity. It is important to note that the

average number of days reflects only those individuals reporting use for that particular category.

Four substance use categories were not included because they represented far fewer cases (n<25,

or 3.1%). Those reporting substance use at baseline typically indicated frequent use, which is

consistent across all categories (i.e., approximately 12-13 days out of the last 30 for each

substance use category).


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Figure 4

In addition to frequent substance use in the last 30 days prior to enrollment at Foundations

Associates, many consumers reported recent treatment for substance use problems. FA serves a

population with extensive treatment histories, which is not unusual for a population with co-

occurring disorders. Participants in the program were often referred from other treatment

facilities where they were receiving treatment focusing on substance use. Of those:

12% were referred from inpatient treatment facilities where they were receiving treatment for

substance use

8% were referred from outpatient treatment programs where they were receiving treatment

for substance use

17% were referred from residential treatment facilities where they were receiving treatment

for substance use

Psychiatric Severity

Clients entering the treatment program at Foundations Associates consistently reported high

levels of symptomatology across all major psychiatric domains. Using the Brief Sytmptom

Inventory (BSI), which has well-established normative data, we can compare the psychiatric

severity of participants to typical mental health consumers in outpatient settings. Relative to BSI

normative data for psychiatric outpatient consumers, program participants tend to fall around the


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60th to 70th percentile in psychiatric severity (i.e., the average Foundations consumer scores

higher than 60 to 70 percent of typical psychiatric outpatients). Compared to general (i.e., non-

psychiatric) population norms, the average FA consumer reported psychiatric symptom severity

in the 95th to 99th percentile range. Table 2 below compares the BSI scores of FA program

participants to BSI outpatient norms and BSI census norms.

Table 2 Percentile Rank – Psychiatric Severity

Symptoms BSI Outpatient Norms

BSI Census Norms

Somatization 68.9% 93.4% Obsessive-Compulsive 68.2% 97.7% Interpersonal Sensitivity 59.7% 96.5% Depression 59.2% 98.0% Anxiety 57.4% 97.5% Hostility 61.5% 94.1% Phobia 70.5% 96.1% Paranoia 74.3% 97.4% Psychosis 74.1% 99.0% Global Severity 69.3% 98.7%

Figure 5 below helps illustrate that psychiatric severity is higher for program participants

compared to mental health outpatient norms and census norms. Across all psychiatric domains,

FA participants experience psychiatric symptomatology that is more severe than the majority

(i.e. greater than 50%) of those in the outpatient and census normative groups. Although there is

some fluctuation across domains, the global severity category indicates that the average FA

participant reports higher symptom severity than almost 70% of psychiatric outpatients.


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Figure 5

Consistent with BSI baseline scores, the Mental Component Summary from the SF-12 also

suggests that participants face substantial psychiatric impairment compared to general population

norms. The Mental Component score for the general population has a mean of 50 and a standard

deviation of 10 points. The above graph shows that program participants have an average score

that is almost two standard deviations lower than the norm, indicating psychiatric conditions that

present a large burden on mental health status. BSI domain scores and SF-12 summary measures

indicate that consumers served by Foundations Associates have greater psychiatric impairment

than general psychiatric outpatient populations.

Associated Problems – Medical, Family/Social, Economic, Housing, and Legal Problems

Subjective items from the Lehman’s Quality of Life Interview offer a general description of

associated problems from the consumers’ perspective as they enter treatment (See Figure 6). All

major categories are somewhat consistent except reported satisfaction with finances. Participants

indicated considerably less satisfaction with finances on subjective items compared to the other

categories.


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Figure 6

Additional baseline data helps provide further details for each of the categories listed in the

above figure:

Medical Problems

o 43.7% reported a history of head trauma

o 31.1% reported a major medical physical illness

o 34.6% reported chronic physical pain

Family/Social Problems

o 58.3% reported moderate (19.2%), quite a bit (23.2%) or extreme difficulty

(15.9%) with family relationships

o 39.5% reported moderate (14.3%), quite a bit (14%) or extreme difficulty (11.2%)

with relationships with friends

Economic Problems

o 82.6% received less than $300 from all income sources combined in the last 30

days

o 29.1% reported full or part time employment

o 51.5% were unemployed and looking for employment


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Housing

Table 3 Housing prior to program

N %

Shelter or safe haven 43 5.3%

Street/outdoors 29 3.6%

Other institution 80 9.8%

Inpatient institution 10 1.2%

Own/rent apartment,

room, or house

258 42.0%

Someone else’s

apartment, room, or house

245 39.8%

Halfway house 62 10.1%

Residential treatment 50 8.1%

While it appears that most participants were

living in their own residence, the measure

itself does not provide an adequate

representation of housing status. However,

the data does help illustrate that most

participants were living in relatively

temporary housing (58%) at baseline (i.e.,

not their own/rent apartment, room, or

house).

Legal Problems

o 29.6% reported moderate (13.6%), quite a bit (1.2%) or extreme difficulty

(14.8%) with legal issues (e.g., being arrested or detained, having to go to trial,

having to meet with probation/parole officer)

o 10.9% were incarcerated overnight in the last 30 days.

Service Utilization

Consumers served by Foundations Associates typically report extensive service utilization

patterns of multiple treatment systems and providers that are unable or unwilling to accept clients

with psychiatric and substance use problems. Those who are able to access treatment often

become frustrated with inconsistent treatment approaches from psychiatric and substance abuse

treatment providers. As a result, individuals with co-occurring disorders often fail to engage in

appropriate treatment and, instead, rely on crisis-based treatment services. Foundations

Associates’ consumers report a history of high cost and ineffective service utilization for

psychiatric related problems. Findings show that:

35.9% received treatment related to mental health problems through Inpatient, Emergency

Room, or Residential treatment services in the last 30 days prior to enrollment at

Foundations.

Of those clients reporting utilization of higher cost services for mental health problems (i.e.,

Inpatient, ER, or Residential treatment) (N=289), only 18.7% reported any Outpatient

treatment services in the past 30 days prior to enrollment.


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Of those accessing Emergency Room services in the past 30 days for mental health problems

(N=146), only 20.5% reported utilization of less costly Outpatient treatment services.

86.9% rated the importance of treatment for mental or emotional difficulties as very

important (17.9%) or extremely important (69%).

80% indicated a past psychiatric diagnosis by a mental health professional.

Population Demographics

FA consumers are generally representative of the metropolitan Davidson County/Nashville, TN

population in terms of gender and ethnicity. Program participants were 52% Female and 48%

Male. Over half of the participants were White (63%), followed by African American (35%),

while only a small percentage were Hispanic/Latino (1%) and American Indian (0.6%). As

expected, program participants were typically 26-45 years of age, and over half were more than

35 years old (54%). Individuals older than age 45 made up 17% of the participants served by the

integrated outpatient treatment program.

Table 4 Demographic Characteristics

Variable N %a

Male 392 48.0% Gender

Female 424 52.0%

White 514 63.0%

Black or African

American

289 35.4%

Hispanic or Latino 8 1.0%

Race/Ethnicityb

American Indian 5 0.6%

18 to 25 121 14.8%

26 to 35 255 31.3%

36 to 45 299 36.6%

Age Group

46 and above 141 17.3%

a Values in this column may not add up to 100% due to rounding

b Categories with null responses were excluded

Compared to Davidson County and the Nashville metropolitan area, FA program participants

were less likely to be older than 45 years of age as the average age was 36 (±9 years) and ages

ranged from 18 to 61. There were also fewer White participants and a larger percentage of Black

or African American participants compared to the Davidson County and Nashville general

population (US Census Bureau, 2003).


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One perhaps unexpected finding stemming from this descriptive analysis is the diversity in

educational attainment. Most program participants completed high school (60.3%), though only

7.2% graduated from college. To some degree, this suggests a reasonable degree of literacy.

Given the range of educational backgrounds, FA modified its interviewing process to

accommodate those needing additional assistance. Table 5 below provides more details on

educational status and income levels.

Table 5 Education/Income Demographics

Variable N %a

Did not complete high

school

324 39.7%

High school diploma 274 33.6%

Some college 159 19.5%

Education Level

College graduate 59 7.2%

$300 and below 424 54.9%

$301 - $575 214 27.7%

$576 - $1000 70 9.1%

$1001 - $1500 22 2.8%

Income Level b,c,d

Above $1500 42 5.4%

$300 and below 57 28.6%

$301 - $575 34 17.1%

$576 - $1000 46 23.1%

$1001 - $1500 24 12.1%

Level of income from

wages b,e

Above $1500 38 19.1%

Employed full-time 184 22.6%

Employed part-time 53 6.5%

Unemployed looking

for work

419 51.5%

Unemployed disabled 58 7.1%

Unemployed retired 4 0.5%

Unemployed not

looking for work

28 3.4%

Employment status

Other 67 8.2%

a Values in this column may not add up to 100 due to rounding

b Income refers to pretax income in the last 30 days

c Categories with null responses were excluded


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d Fewer responses are reported under this variable due to missing values (i.e., no income in the last 30

days)

e Reported only for those individuals who indicated income from wages >$0

Table 5 indicates overall monthly income reported for the 30 days prior to treatment. Most

participants (82.6%) reported less than $576 in total income, and of those, 54.9% reported $300

or below. Monthly income represents pre-tax individual income from wages, public assistance,

retirement, disability, family and/or friends’ financial assistance as well as non-legal income.

According to the Department of Health and Human Services, the poverty guideline for a family

unit with one person is $8,980 (Federal Register 2003), which is approximately $748 per month.

The median baseline income for program participants was $142 per month, considerably lower

than HHS poverty guidelines. Only 25.8% of those reporting any income in the last 30 days

reflected earnings from wages. Few participants indicated full or part-time employment in the 30

days prior to intake. Of those who reported full or part time employment, few indicated more

than minimal earnings.


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Program Outcomes

The evaluation of program outcomes relies on several different instruments in order to provide

adequate detail of changes in clinical status over time and across multiple domains. A list of key

domains and corresponding measures collected at baseline, 6-months, and 12-months are listed

in the following table.

Table 6 Outcome Domains and Measures

Outcome Domain Evaluation Instruments Cross-Site Measures

Substance Use TAAD GPRA

Mental/Emotional Health BSI COFD

Physical Health TSR COFD

Functioning Medical Outcomes Study

Short Form-12 Item (SF-12)

Service Utilization TSR GPRA

Housing GPRA

Legal Concerns GPRA

Social/Family Relationships Lehman’s QOL (objective

items)

Employment/Income GPRA

Subjective Quality of Life Lehman’s QOL (subjective

items)

Stage of Change URICA


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Substance Use Outcomes

Cronbach’s alphas calculated for substance use dependence and abuse items were 0.923 for

Alcohol Dependence, 0.894 for Drug Dependence, 0.848 for Alcohol Abuse, and 0.825 for Drug

Abuse. Each of the dependence categories were based on 7 items, while abuse categories were

based on only 4 items. Given the differences in reliability coefficients, which are largely due to

the number of items included in each category, substance use outcomes were calculated using

problem behaviors/symptoms associated with drug and alcohol dependence. In Figure 7 below,

clear differences from baseline to follow-up indicate program success with respect to reducing

problem or risky behaviors associated with alcohol and drug dependence. Minimal change from

6 months to 12 months suggests that the program may help stabilize dependence behaviors and

symptoms.

Figure 7

In Figure 8, substance use at followup is examined for consumers who reported using a given

substance at baseline. The most common drugs of abuse reported by FA consumers were alcohol

and any illegal drug, specifically, crack/cocaine and marijuana. Far fewer consumers reported

substance use 6 and 12 months after intake. Those participants reporting substance use also

reported fewer days of use. It is important to consider that this analysis of substance use is based

on frequency of use, which participants appear to under-report compared to substance use

problems as noted earlier in this report (e.g., fewer participants indicated substance use compared

to those who indicated significant behaviors/consequences related to substance use).


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Figure 8

The harm reduction model presented in Figure 8 illustrates that those participants who reported

frequent use in the 30 days prior to treatment significantly reduced the frequency of substance

use 6 and 12 months after enrolling in FA’s integrated outpatient program. While this is an

indicator of program success, it is also important to consider abstinence as a substance use

outcome because even less frequent substance use behavioral patterns (e.g., binge drinking) can

be particularly problematic for individuals with co-occurring disorders.

While an abstinence model has its advantages and disadvantages, it is common in addictions

research and most fairly represents a consumer’s success in addressing addiction problems with

problem substances. By including consumers who report no baseline use for a given substance in

the followup outcomes, followup abstinent rates would be improved, but would not accurately

reflect program effectiveness. The primary weakness of this method is that limitations in sample

size may sometimes become a factor when analyses are restricted to a single substance with

complete followup data. This is why abstinence rates were only calculated for the most common

substances reported, as calculations for rarer substances (e.g., heroin, amphetamines, etc.) would

have reduced sample size to the point where abstinence rates would be unreliable. All data

presented in the following abstinence model (Figure 9) were gathered using the GPRA substance


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use questions that are identical to ASI alcohol and drug use items (e.g., During the past 30 days

how many days have you used the following: Any Alcohol, Alcohol to Intoxication…).

Figure 9

One interesting result of this analysis is that Foundations apparently has slightly better success in

reducing alcohol-use-to-intoxication and illegal drug use (i.e., cocaine and marijuana) relative to

alcohol use (not to intoxication). Previous studies with consumers in Foundations’ integrated

residential treatment program (Doub, 2001) found the same general pattern. One interesting

exception is the difference in abstinence rates for alcohol-use-to-intoxication, which is higher for

consumers in the current study’s integrated outpatient program. Particularly with respect to 12

month outcomes, abstinence rates for consumers in the outpatient program are 79% versus 61%

for consumers in the integrated residential program. While the significance of this observation

should not be exaggerated, this pattern does suggest the possibility of some differences in the

way consumers respond to lower intensity services over a longer period of time compared to

high intensity and short-term integrated treatment services.

Along with a decrease in substance use at followup, FA participants also reported fewer

problems related to substance use (See Figure 10). It should be noted that each of these items

captured using the GPRA tool is based on a single item for each category. However, the pattern

does suggest that a decrease in alcohol use for many consumers at FA resulted in less stress,

fewer days with reduced activity, and less emotional problems.


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Figure 10

Psychiatric Outcomes

The Brief Symptom Inventory (BSI) was included in the evaluation to provide a comprehensive

assessment of psychiatric symptoms as the primary psychiatric outcome measure in this report.

The BSI is a 53-item self-report measure that has proven useful as a clinical and research tool,

and has been used widely in mental health assessment applications. One significant benefit of

using the BSI is the ability to standardize scores in terms of clinical or census-based normative

groups. That means that the range of scores for certain groups, such as the general public or

psychiatric inpatients has already been determined. This allows one to accurately gauge the

relative severity of psychiatric symptoms by comparing the BSI scores to other populations. For

the purposes of this analysis, BSI scale scores are calculated using norms provided for

psychiatric outpatients.


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Figure 11

Consumers reported substantial reductions in psychiatric symptomatology across all BSI

domains following treatment in FA’s outpatient integrated treatment program. At program

intake, the average FA consumer indicated psychiatric symptoms in six areas that were more

severe than approximately 70% of persons receiving outpatient psychiatric services. After

treatment, the average FA consumer reported less psychiatric impairment than the average

person receiving outpatient mental health services.

While treatment appears to improve psychiatric stability and reduce associated symptoms across

the board, it is clear that FA’s consumers have ongoing mental health needs. All BSI domains

indicated significant reductions from baseline to followup, but some of the more persistent

psychiatric symptoms (e.g., phobia, paranoia, and psychosis) were not reduced much further than

the average outpatient normative group. Further analysis of specific symptoms reported on the

COFD assessment helps further explain this pattern (See Figure 12). There was only a minimal

reduction in the percentage of clients who reported experiencing problems with hallucinations in

the last 30 days. This could suggest that consumers with more severe psychiatric impairment do

not improve as dramatically over the course of a one year longitudinal study. However, we

should be careful when drawing assumptions because each of the categories shown in Figure 12

are based on single questions from the COFD assessment, and indicate existence of the problem

rather than severity of the problem.


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Figure 12

Based on data collected using the Treatment Services Review (TSR), treatment appeared to

reduce and stabilize the number of symptomatic days experienced by participants (See Figure

13). When viewed in terms of the number of days a consumer experienced mental health

problems in the month prior to each interview, treatment appeared to reduce symptomatic days

by approximately 70% (baseline to 6 months) and 75% (baseline to 12 months). It is also

noteworthy that consumers appeared to stabilize psychiatrically, maintaining treatment gains

even 12 months after intake.


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Figure 13

Medical Problems

Program success is clearly indicated by the primary outcome measures already detailed within

this report; however, it is also important to consider associated outcomes, such as general

medical problems with individuals who often had extensive co-morbid physical disorders. Figure

14 presents physical and mental component summary scores (PCS/MCS). Lower scores indicate

greater impairment with 50 (reference line) equal to general population norms. As expected, the

measures indicate greater initial impairment and greater improvement on the mental component

summary compared to the physical component. While physical component summary outcomes

show some improvement at followup, relatively minimal indication of baseline physical

impairment is somewhat surprising.


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Figure 14

In order to better understand patterns of physical medical problems for program participants,

subjective items from the Treatment Services Review offer further support of relatively stable

physical functioning suggested by the PCS scores in the previous chart. Figure 15 shows that

participants also reported similar number of days with medical problems across all three data

collection points. However, in contrast to the PCS, subjective items in Figure 16 indicate greater

perceived need for treatment of physical medical problems at followup. The data reported in

Figure 15 and Figure 16 are based on single items from the Treatment Services Review and are

therefore less accurate measures of physical impairment/problems. Despite this limitation, the

pattern may indicate greater knowledge of medical symptoms and problems after effectively

treating substance use and mental health symptoms. It is possible that consumers prioritized

issues related to substance use and mental health treatment at the initial intake interview, thus

minimizing subjective physical complaints at baseline. While it is also possible that this trend

represents an inevitable decline in physical health over time, the SF-12 outcomes that rely on

subjective and objective measures suggest stable physical health.


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Figure 15

Figure 16


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Quality of Life Outcomes

Although subjective items are often difficult to interpret, consumer perspective is particularly

important with respect to quality of life outcomes. Lehman’s Quality of Life (QOL) offers

subjective ratings based on several items for each category. For each item, the respondent must

indicate level of satisfaction using a scale from one to seven (1 = Terrible…7 = Delighted). Each

domain contains more than one item, therefore the average is calculated to determine the

corresponding domain score (Table 7).

In contrast to the subjective medical outcomes reported in the previous section, subjective QOL

health ratings in Table 7 indicate greater change over time. The health domain is a broader

measure that combines physical and mental health ratings, but the findings below suggest that

consumers generally feel better about their health after treatment despite greater awareness of

physical health problems.

Table 7 Quality of life outcomes (subjective items)

Average subjective rating from 1=terrible to 7=delighted Measure Domains

Baseline 6-months 12-months

Healtha 3.5 4.2 4.3

Familya 3.5 4.2 4.3

Leisure activitiesa 3.4 4.1 4.2

Financesa 2.4 2.9 3.1

Housinga 3.7 4.3 4.2

Legal and safety

issuesa

4.5 4.8 5.0

Overall life

satisfactiona

3.1 4.2 4.4

a All differences statistically different (p<0.05) based on two-sided tests for baseline to 6-months and

baseline to 12-months comparison of mean

Family/Social Outcomes

The QOL outcomes indicate substantial improvement in satisfaction with family relationships.

Objective items from the Lehman’s QOL provide further evidence of an improvement in family

functioning. The following chart, Figure 17, shows that the average amount of contact with

family and friends is consistent at each data point, while Table 6 indicates that these contacts are

far more positive at followup compared to the contacts at baseline. For example, the average

family contact indicated in Figure 17 is 2.63 (i.e., more than once per month but less than weekly

contact with family members) at baseline and 2.50 at 12 months.


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Figure 17

Additional analysis of family/social outcomes was done using COFD items indicating level of

difficulty with family, friends, and social activities (Figure 18). COFD items provide 5 possible

responses ranging from no difficulty to extreme difficulty. In order to provide a clearer

indication of social relationship outcomes, positive outcomes were indicated if consumers

reported no difficulty. Only 20% of all participants reported no difficulty with family

relationships at baseline. At followup, this percentage increased to 49% and 55% for six and

twelve month assessments, respectively. The following chart clearly illustrates consistent

improvement in family, social, and leisure activities outcomes.


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Figure 18

Finances

Most consumers entering treatment at Foundations Associates earned minimal wages at most and

there was only modest improvement in subjective ratings of finances from baseline to followup.

One possible explanation is apparent after further analysis of changes in employment status from

baseline to followup (Table 8). A far greater proportion of consumers were unemployed looking

for work at baseline (51.5%) compared to the proportion at followup (29% at 6 months and 22%

at 12 months). There was an increase in the proportion of consumers employed part time and

unemployed disabled from baseline to follow-up, while the proportion of consumers employed

full time remained around 23% across all three data collection points. This pattern suggests that

more consumers had successfully gained access to some income, but few were able to access full

time employment. As a result, finances improved but income continued to be a problem for

many consumers because disability and part time employment do not provide adequate resources

to significantly improve quality of life.

Table 8 Employment status over time

Baseline 6-Months 12-Months


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Employment

Status

Baseline 6-Months 12-Months

Employment

Status

Employed

full-time

184 22.6% 157 22.6% 126 23.9%

Employed

part-time

53 6.5% 72 10.3% 61 11.6%

Unemployed

looking for

work

419 51.5% 205 29.5% 117 22.2%

Unemployed

disabled

58 7.1% 103 14.8% 96 18.2%

Unemployed

volunteer

0 0.0% 2 0.3% 3 0.6%

Unemployed

retired

4 0.5% 0 0.0% 5 0.9%

Unemployed

not looking

for work

28 3.4% 47 6.8% 46 8.7%

Other 67 8.2% 110 15.8% 73 13.9%

It is noteworthy that the 23% employed full time at baseline reported dramatic increases in

income from wages at followup. Figure 19 shows that the wages paid to those employed full

time went from $839 in the last 30 days at the baseline interview to $1,327 in the last 30 days for

those employed full time at the six month follow-up interview. In addition, these gains appeared

to stabilize as 12 month wages ($1,275 in the last 30 days) declined only slightly from 6 months,

but remain significantly improved from baseline. While self-reported income is a highly variable

statistic, the stability of employment coupled with substantial increases in wages suggest that the

program may have a positive financial impact on consumers at all levels of employment.


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Figure 19

Housing Outcomes

Consumers were increasingly housed in more permanent arrangements after enrollment in the

program at Foundations Associates (See Figure 20). For example, 70% of consumers were

housed in their own or someone else’s apartment room or house 12 months after enrollment

compared to 56% at baseline. Consumers living in a shelter or on the street decreased from 14%

at baseline to 6% 12 months following enrollment in the program. As expected, given these

improvements in housing situations, consumers reported far greater satisfaction with housing, as

mentioned earlier in the QOL outcomes section of this report.


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Figure 20

Incarceration

In the criminal justice population, rates for alcohol and drug disorders are four to seven times

higher than the general population, and rates for mental health disorders are four times higher.

Most participants did not report any new arrests in the last 30 days prior to enrollment in the

program (i.e., baseline). Of those who indicated baseline arrests (8.2%), even fewer reported new

arrests in the 30 days prior to six month (6.15%) and 12 month (6.24%) followup assessments

(See Figure 21). Arrests for drug related offenses also declined from more than 4% at baseline to

just 1% at the 6 month and 12 month followup.


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Figure 21

Service Utilization

In Figure 22, overall service utilization trends clearly miss some important differences in service

utilization over time within each type of service (i.e., Inpatient, Emergency Room, and

Outpatient Services). Based on self-reported use of services in the 30 days prior to each

assessment (GPRA questions), combined service use appeared to increase six months after

enrollment in the program. This increase is due to higher utilization of outpatient services at six

months (49.1%) compared to baseline (18.9%). In contrast, utilization of emergency room and

inpatient services declined from baseline to six months (4% and 15% decline for each category,

respectively). The decline in inpatient and emergency room services continued at twelve months,

along with a slight decline in outpatient service utilization. This pattern suggests that the

program successfully transitioned participants from high-cost reactive services (i.e., ER and

Inpatient) to more appropriate and sustainable outpatient services.


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Figure 22

Particularly for services related to substance abuse and mental health problems, there was a

dramatic shift from high cost, high intensity, and short term services to more sustainable and

inexpensive outpatient services (See Table 9). Utilization of services related to physical medical

problems did not indicate a similar trend over time. A slightly greater percentage reported

emergency room services for physical medical problems at 6 months (15.6%) and 12 months

(12.3%) compared to emergency room services for substance abuse and mental health problems

combined at 6 months (12.3%) and 12 months (6.8%). However, it is difficult to draw any

meaningful comparisons based on reasons for service use (i.e., physical, substance use, or mental

health problems) because services are usually related to a combination of medical/behavioral

health problems. For example, 22 out of the 78 (28%) who indicated ER utilization for physical

problems in the 30 days prior to enrollment also indicated ER use for mental health problems as

well.

Table 9 Percentage receiving services in the last 30 days

Baseline 6-Months 12-Months Service Utilization Category

n % n % n %

Inpatient for physical problems 25 3.1% 18 2.6% 20 3.8%

Inpatient for mental health problems 144 17.8% 67 9.6% 37 7.0%


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Inpatient for substance abuse problems 98 12.1% 55 7.9% 28 5.3%

Outpatient for physical problems 9 1.1% 32 4.6% 19 3.6%

Outpatient for mental health problems 95 11.7% 313 44.9% 164 31.1%

Outpatient for substance abuse problems 65 8.0% 226 32.5% 139 26.3%

Emergency room for physical problems 79 9.7% 109 15.6% 59 11.2%

Emergency room for mental health problems 106 13.0% 49 7.0% 25 4.7%

Emergency room for substance abuse

problems

49 6.0% 37 5.3% 11 2.1%


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Conclusion Based on empirically supported findings from Foundations Associates’ residential integrated

treatment program, the current project sought to modify and expand FA’s outpatient services by

replicating and adopting the same key principle components of integrated treatment. Previous

findings translated key elements of integrated treatment for co-occurring disorders into

successful treatment for the complex needs of individuals with both mental health and substance

use disorders. Despite these findings, the impact of residential treatment services is limited by

demanding economic and personal level of commitment that are simply not feasible in many

situations. As such, replicating the residential model in an outpatient could potentially reach a

broader audience.

One of the key challenges was how to replicate a residential integrated treatment model in an

outpatient setting. Despite increasingly mainstream attention to integrated treatment services,

implementing these services continues to be challenging. Unfortunately, knowledge of broad

integrated treatment philosophies does not always translate to delivery of integrated principles.

Efforts to change traditional treatment delivery services must overcome multiple layers of

resistance in order to effectively implement integrated treatment. Foundations Associates does

not have to overcome inconsistent agency philosophies because it was founded as an integrated

treatment provider ten years ago. As the agency continues to grow, however, FA continues to

spend significant time and effort training staff who come from a variety of philosophical

treatment backgrounds. Given an obvious lack of practical guidelines that address how to apply

broad integrated treatment constructs in unique settings, the project documented a practical guide

to integrated treatment based on first-hand experience.

While this evaluation provides strong evidence of the effectiveness of Foundations Associates’

integrated treatment model for this population, it will be important in the future to further

replicate the program model in other agency and geographic locations in order to better

understand treatment process and related outcomes. This project has assisted FA to more clearly

define and document an operational guide to integrated treatment principles and concepts.

Dissemination of materials that address practical issues and help translate current widespread

knowledge of more general integrated treatment constructs is an important step towards more

clearly understanding its impact on treatment process and outcomes.

foundations associates: expansion and enhancement grant ......including relapse prevention, trauma...

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