integration of care for co-occurring disorders begins at intake roshni chatterjee, lpc director of...
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INTEGRATION OF CARE FOR INTEGRATION OF CARE FOR CO-OCCURRING DISORDERS CO-OCCURRING DISORDERS
BEGINS AT INTAKEBEGINS AT INTAKE
Roshni Chatterjee, LPCRoshni Chatterjee, LPCDirector of IntakeDirector of Intake
Community ConnectionsCommunity ConnectionsWashington DCWashington DC
IntegrationIntegration
RationaleRationale
GoalGoal
ImplementationImplementation
OutcomesOutcomes
RationaleRationale
100% of consumers seen at100% of consumers seen at
intake present with a majorintake present with a major
mental illnessmental illness• SchizophreniaSchizophrenia• Bi-polar DisorderBi-polar Disorder• Affective DisordersAffective Disorders
90% of consumers at intake 90% of consumers at intake
present with a co-occurring present with a co-occurring
substance abuse disorder.substance abuse disorder.• Crack Crack • AlcoholAlcohol• MarijuanaMarijuana• PolysubstancePolysubstance
Intake staff needed further training in order to address the needs of Intake staff needed further training in order to address the needs of this priority populations. this priority populations.
Information gathered by the intake department will inform the agency Information gathered by the intake department will inform the agency about the prevalence and incidence of dual disorder in the referral about the prevalence and incidence of dual disorder in the referral pool and hence will impact agency wide service decisions.pool and hence will impact agency wide service decisions.
GoalGoal
My Goal:My Goal:
Improve the ability of the IntakeImprove the ability of the Intake
Team at Community Connections to Team at Community Connections to
accurately identify, assess and categorize accurately identify, assess and categorize
new Dually Diagnosed (DD) clients.new Dually Diagnosed (DD) clients.
ImplementationImplementation
INTAKEINTAKETRAININGTRAININGMODULEMODULE
SCREENING:SCREENING:
InterviewInterviewMSEMSE
MIDASMIDAS
ASSESSMENT:ASSESSMENT:
LongitudinalLongitudinalintegratedintegrated
assessment ofassessment ofco-occurringco-occurring
disordersdisorders
TREATMENTTREATMENT&&
RESOURCES:RESOURCES:
APRAAPRA
ScreeningScreening1.1. Interview Framework:Interview Framework:
95% of our consumers have co-occurring disorders. 95% of our consumers have co-occurring disorders. Know your own bias.Know your own bias. Don’t forget to ask questions if you want the answers!Don’t forget to ask questions if you want the answers! Recognize what you see.Recognize what you see.
2.2. MIDAS MIDAS ((Minkoff, K. 2001)) A self-report toolA self-report tool Refers to previous six months Refers to previous six months Any “yes” answer could indicate a problem with drugs/alcoholAny “yes” answer could indicate a problem with drugs/alcohol Some differentiation between abuse/dependenceSome differentiation between abuse/dependence Some specific internal decision rulesSome specific internal decision rules Follow up with assessmentFollow up with assessment
3.3. Mental Status Exam Mental Status Exam The MSE is the basis for understanding the client's presentation The MSE is the basis for understanding the client's presentation
and and beginning to conceptualize their functioning into a diagnosis.beginning to conceptualize their functioning into a diagnosis.
Screening - Screening - The MIDASThe MIDAS
Self Report about drug/alcohol Self Report about drug/alcohol
problemsproblems
Self assessmentSelf assessment
Doctor’s assessmentDoctor’s assessment
Family’s assessmentFamily’s assessment
Related legal problemsRelated legal problems
Complications of medical problemsComplications of medical problems
Interaction of drug & mental health Interaction of drug & mental health
issuesissues
Drugs to relieve MH problemsDrugs to relieve MH problems
Drugs worsen MH problemsDrugs worsen MH problems
Problem with med compliance due to Problem with med compliance due to
drugsdrugs
Feelings of:Feelings of:
Symptoms of withdrawalSymptoms of withdrawal
Guilt due to drug useGuilt due to drug use
Being out of control due to drug useBeing out of control due to drug use
Belief that one is an addict or Belief that one is an addict or alcoholicalcoholic
Self report of:Self report of:
Problem with provider, school, workProblem with provider, school, work
Increase in ER visits DetoxIncrease in ER visits Detox
Related Psychiatric hospitalizationRelated Psychiatric hospitalization
Attendance at AA/NAAttendance at AA/NA
Other SA TreatmentOther SA Treatment
Screening - Screening - Mental Status ExamMental Status Exam
OrientationOrientation Rapport and AttitudeRapport and Attitude AppearanceAppearance MoodMood AffectAffect SpeechSpeech Thought ProcessThought Process Thought ContentThought Content DangerousnessDangerousness HallucinationsHallucinations InsightInsight JudgmentJudgment
BehaviorBehavior CognitionCognition Memory Memory (please indicate good, (please indicate good,
fair, or impaired for each)fair, or impaired for each) Psychomotor ActivityPsychomotor Activity SleepSleep Appetite Appetite Substance UseSubstance Use General Psychiatric ConditionGeneral Psychiatric Condition
AssessmentAssessment
Recognizing, conceptualizing and categorizing substance Recognizing, conceptualizing and categorizing substance abuse and mental health symptoms are key components of abuse and mental health symptoms are key components of the intake process…the intake process…
Issues in assessing co-existing disordersIssues in assessing co-existing disorders Key QuestionsKey Questions Sub-groups of people with co-existing disordersSub-groups of people with co-existing disorders Stages of ChangeStages of Change Phases of RecoveryPhases of Recovery Stages of TreatmentStages of Treatment
Issues in Assessment*Issues in Assessment*
Assessment PrinciplesAssessment Principles
Relationship basedRelationship based IntegratedIntegrated LongitudinalLongitudinal Strengths BasedStrengths Based ComprehensiveComprehensive ContinuousContinuous SystematicSystematic
**CCISC from Ken Minkoff, MDCCISC from Ken Minkoff, MD
Assessment ContentAssessment Content
StrengthsStrengths SymptomsSymptoms Successful TreatmentSuccessful Treatment Stage of Change, TreatmentStage of Change, Treatment SupportsSupports Spiritual and Cultural Spiritual and Cultural
FrameworkFramework SkillsSkills Somatic IssuesSomatic Issues Significant Problems or Significant Problems or
ContingenciesContingencies
Key Questions in AssessmentKey Questions in Assessment
Substance Abuse ?Substance Abuse ? When did you start using drugs?When did you start using drugs? What drugs have you used in your life? What is your drug of choice?What drugs have you used in your life? What is your drug of choice? Are you experiencing withdraws or other medical problems?Are you experiencing withdraws or other medical problems? Tell me about your treatment history…Tell me about your treatment history… How much clean/sober time do you have?How much clean/sober time do you have? How easy was it for you to access servicesHow easy was it for you to access services
Mental Health ?Mental Health ? What is the presenting problem?What is the presenting problem? Are you in crisis – SI/HI?Are you in crisis – SI/HI? What symptoms are you experiencing?What symptoms are you experiencing? What medications are you taking and who is your doctor?What medications are you taking and who is your doctor? What is your treatment/hospitalization history?What is your treatment/hospitalization history? What services are you looking for?What services are you looking for?
Assessing Assessing Subgroups*Subgroups*SUB-GROUPS OF PEOPLEWITH COEXISTING DISORDERS:
Patients with “Dual Diagnosis” – Patients with “Dual Diagnosis” – combined psychiatric combined psychiatric and substance and substance abuse problems – abuse problems – who are eligible forwho are eligible forservices fall into four major services fall into four major Quadrants.Quadrants.
*Minkoff, K CCiSC 2001CCiSC 2001
PSYCH. HIGHPSYCH. HIGH
SUBSTANCE HIGHSUBSTANCE HIGH
Serious & Persistent Serious & Persistent MentalMental
Illness with Substance Illness with Substance DependenceDependence
QUADRANT IVQUADRANT IV
PSYCH. LOWPSYCH. LOW
SUBSTANCE HIGHSUBSTANCE HIGH
Psychiatrically Psychiatrically ComplicatedComplicated
Substance DependenceSubstance Dependence
QUADRANT IIIQUADRANT III
PSYCH. HIGHPSYCH. HIGH
SUBSTANCE LOWSUBSTANCE LOW
Serious & Persistent Serious & Persistent MentalMental
Illness with Substance Illness with Substance AbuseAbuse
QUADRANT IIQUADRANT II
PSYCH. LOWPSYCH. LOW
SUBSTANCE LOWSUBSTANCE LOW
Mild Psychopathology Mild Psychopathology withwith
Substance AbuseSubstance Abuse
QUADRANT IQUADRANT I
Assessing Assessing Stage of Change*Stage of Change*
In order to engage a client effectively at intake it is In order to engage a client effectively at intake it is critical to meet the client where they are with critical to meet the client where they are with their recovery/treatment:their recovery/treatment:
Pre-contemplationPre-contemplation ContemplationContemplation PreparationPreparation ActionAction EvaluationEvaluation
*Minkoff, K & Cline, C., CCISC 2001, CCISC 2001
Assessing Assessing Phase of Recovery*Phase of Recovery*
Both substance dependence and mental illness are disorders which canbe understood using a disease and recovery model with parallel phases of recovery. Recommendations made at intake about the current phase of recovery has implications for engagement and prioritizing treatment needs.
PHASE 1: StabilizationPHASE 1: Stabilization- Stabilization of active substance use or acute psychiatric symptoms- Stabilization of active substance use or acute psychiatric symptoms
PHASE 2: Engagement/Motivational EnhancementPHASE 2: Engagement/Motivational Enhancement- Engagement in treatment - Engagement in treatment - Contemplation, Preparation, Persuasion- Contemplation, Preparation, Persuasion
PHASE 3: Prolonged StabilizationPHASE 3: Prolonged Stabilization- Active treatment, Maintenance, Relapse Prevention- Active treatment, Maintenance, Relapse Prevention
PHASE 4: Recovery & RehabilitationPHASE 4: Recovery & Rehabilitation- Continued sobriety and stability- Continued sobriety and stability- One year – ongoing- One year – ongoing
**Minkoff, K CCiSC 2001CCiSC 2001
Assessing SAssessing Stage of Treatment*tage of Treatment*
EngagementEngagement - Lack of working alliance- Lack of working alliance
Early Persuasion Early Persuasion - Working alliance with some discussion about SA and MI issues- Working alliance with some discussion about SA and MI issues
Late PersuasionLate Persuasion- Engaged and there is a reduction in use for 1 month- Engaged and there is a reduction in use for 1 month
Early Active TreatmentEarly Active Treatment - Reduced use, working towards abstinence and improved well being.- Reduced use, working towards abstinence and improved well being.
Late Active TreatmentLate Active Treatment- Acknowledges SA as a problems, achieves abstinence and manages - Acknowledges SA as a problems, achieves abstinence and manages
symptoms < 6 months.symptoms < 6 months.
Relapse PreventionRelapse Prevention- Acknowledges SA as a problems, achieves abstinence and manages - Acknowledges SA as a problems, achieves abstinence and manages
symptoms for at least 6 months.symptoms for at least 6 months.
*Drake, R.E., Dartmouth-New Hampshire Psychiatric Research Center *Drake, R.E., Dartmouth-New Hampshire Psychiatric Research Center
Recommendations & ResourcesRecommendations & Resourcesfor Treatmentfor Treatment
Stage specific treatment recommendations:Stage specific treatment recommendations:General treatment Issues for DD population –Stabilization of acute symptoms followed by housing, establishing a working alliance, counseling and psycho-education needs, family issues, practical help and benefits, medication coordination.
Substance Abuse resources Substance Abuse resources APRAAPRA
Mental Health resourcesMental Health resourcesCPEPCPEPCommunity Support AgenciesCommunity Support Agencies
Stage Specific Treatment Stage Specific Treatment Recommendations*Recommendations*
StabilizationStabilization Hospitalization, Detox, Incarceration, Crisis Houses, ACT Teams, Civil CommitmentHospitalization, Detox, Incarceration, Crisis Houses, ACT Teams, Civil Commitment
Engagement Engagement Focus - Wet Housing Outreach, Support in community, What client wants, Initial Focus - Wet Housing Outreach, Support in community, What client wants, Initial exploration, Without contingency, Facilitate access, provide practical assistanceexploration, Without contingency, Facilitate access, provide practical assistance
PersuasionPersuasionFocus - Damp Housing, Expect slips, Cognitive Behavioral, Focused, specific info, Focus - Damp Housing, Expect slips, Cognitive Behavioral, Focused, specific info, Involve family in tx, Improve standard of living, Help with cravings, detox.Involve family in tx, Improve standard of living, Help with cravings, detox.
Active TreatmentActive Treatment Focus - Dry Housing, Expect slips, Cognitive Behavioral, Focused, specific info, InvolveFocus - Dry Housing, Expect slips, Cognitive Behavioral, Focused, specific info, Involve family in tx, Improve standard of living, Help with cravings, detoxfamily in tx, Improve standard of living, Help with cravings, detox
Relapse PreventionRelapse PreventionMore independent, Increase self-efficacy and self advocacy, Self-help, RP plans, Health, More independent, Increase self-efficacy and self advocacy, Self-help, RP plans, Health, well-being, Repair burned bridges, Teach negotiation skills, recognition of early warning.well-being, Repair burned bridges, Teach negotiation skills, recognition of early warning.
*Mueser, K.T. and Drake, R.E.*Mueser, K.T. and Drake, R.E.
Substance Abuse ResourcesSubstance Abuse Resources
APRA: Addiction Prevention and Recovery APRA: Addiction Prevention and Recovery AdministrationAdministration
Contact and Referral Information:Contact and Referral Information:
825 North Capitol Street, NE825 North Capitol Street, NEWashington, DC 20002Washington, DC 20002Telephone: (202) 442-9152Telephone: (202) 442-9152Hours of Operation: 8:30 am - 5:30 pmHours of Operation: 8:30 am - 5:30 pmhttp://app.doh.dc.gov/about/index_apr.shtmhttp://app.doh.dc.gov/about/index_apr.shtm
24 Hour Hotline: 1(888) 7WE-HELP 24 Hour Hotline: 1(888) 7WE-HELP
A sA special thank you to Bonita Bantom, LICSW for taking the time to come to Community pecial thank you to Bonita Bantom, LICSW for taking the time to come to Community Connections to train us on services offered by APRA and the referral process. Connections to train us on services offered by APRA and the referral process.
APRAAPRA APRA is DC’s single state agency on substance abuse prevention and APRA is DC’s single state agency on substance abuse prevention and
treatment. Under the Department of Health, it is the primary provider of treatment. Under the Department of Health, it is the primary provider of substance abuse services for insured and uninsured DC residents.substance abuse services for insured and uninsured DC residents.
APRA conceptualizes Substance Abuse disorders as “biopsychosocial” in APRA conceptualizes Substance Abuse disorders as “biopsychosocial” in nature and gears it’s services to meet the needs of the whole person.nature and gears it’s services to meet the needs of the whole person.
APRA’s role in DC includes: APRA’s role in DC includes: PlanningPlanning & implementing the City-Wide Comp Substance Abuse & implementing the City-Wide Comp Substance Abuse
Strategy.Strategy. Managing community based Primary & Secondary Managing community based Primary & Secondary preventionprevention
programs.programs. Providing a comprehensive array of Providing a comprehensive array of treatmenttreatment services.services. Administers standard of care Administers standard of care certificationcertification requirement for providers. requirement for providers.
APRA: Innovative Treatment Initiatives:APRA: Innovative Treatment Initiatives:
Aftercare Assessments and Referrals
Certification Detoxification Services Drug Treatment Choice Program Employment Services (APEX) Outpatient Services
Prevention and Youth Treatment Services
Primary Medical Care Project Orion
Residential Services Special Population Services Special Services for Persons with
HIV/AIDS
Special Services for Latinos Special Services for LBGT
Community Special Services for Mental Health Special Services for Seniors Special Services for Women with
Children Spiritual Faith Groups
12-Step Meeting Information
Mental Health ResourcesMental Health Resources
Department of Mental Health (DMH)* Services:Department of Mental Health (DMH)* Services:
Adult Forensics Adult Forensics Child & Family Therapy Child & Family Therapy Comprehensive Psychiatric Emergency Program Comprehensive Psychiatric Emergency Program Educational Services Educational Services Homeless Services Homeless Services Individual & Group Therapy Individual & Group Therapy Infants, Toddlers, & Parents Infants, Toddlers, & Parents Multicultural Services Multicultural Services Organizational Development Organizational Development Mental Health Rehabilitation ServicesMental Health Rehabilitation Services
* * http://dmh.dc.gov/dmh/site/default.asphttp://dmh.dc.gov/dmh/site/default.asp
MHRS ServicesMHRS Services Crisis & EmergencyCrisis & Emergency
24 Hour Access Helpline (1-888-7WE-HELP) Crisis and Emergency24 Hour Access Helpline (1-888-7WE-HELP) Crisis and Emergency CPEPCPEP Crisis Houses – Jordan House and Crossing PlaceCrisis Houses – Jordan House and Crossing Place
Community SupportCommunity Support 11 Core Services Agencies – Cal AHL for referral.11 Core Services Agencies – Cal AHL for referral.
Day Services/Intensive Day ServicesDay Services/Intensive Day Services Life Stride - (202) 635-2320Life Stride - (202) 635-2320 McClendon Center - (202) 737-6191 McClendon Center - (202) 737-6191 PSI - (202) 547-3870 PSI - (202) 547-3870
Community Based Intervention (CBI)Community Based Intervention (CBI) Youth Villages- (865) 560-2548 Youth Villages- (865) 560-2548 Home First Care -(202) 737-2554 Home First Care -(202) 737-2554 Beyond Behaviors -(703) 658-9300 Beyond Behaviors -(703) 658-9300 Family Preservation Services - (202) 543-0387 Family Preservation Services - (202) 543-0387
Assertive Community Treatment (ACT)Assertive Community Treatment (ACT) DCCSA - (202) 671-4010 DCCSA - (202) 671-4010 Pathways to Housing -(202) 393-5611 Pathways to Housing -(202) 393-5611 Psychotherapeutic Outreach Services -(202) 588-9540Psychotherapeutic Outreach Services -(202) 588-9540
Community ConnectionsCommunity Connections
Community Connections is a Core Service Agency located in SE Washington DC. It Community Connections is a Core Service Agency located in SE Washington DC. It employs approximately 300 staff members and serves 2000 consumers.employs approximately 300 staff members and serves 2000 consumers.
Integrated intakes are completed daily by licensed clinicians.Integrated intakes are completed daily by licensed clinicians.
Consumers are assigned to one of the following specialty teamsConsumers are assigned to one of the following specialty teams TraumaTrauma HIV/WellnessHIV/Wellness RecoveryRecovery ForensicForensic Dual DisorderDual Disorder Children/AdolescentsChildren/Adolescents
Additional Services:Additional Services: Psychiatric ClinicPsychiatric Clinic Day Services and Community Support GroupsDay Services and Community Support Groups Psychotherapy ClinicPsychotherapy Clinic Supported EmploymentSupported Employment Benefits SpecialistBenefits Specialist
Multiple Research ProjectsMultiple Research Projects
OutcomesOutcomes
1.1. 6 intake staff trained on integrated assessment of dual 6 intake staff trained on integrated assessment of dual disorders.disorders.
2.2. 300 integrated assessment completed since 300 integrated assessment completed since September 1, 2006.September 1, 2006.
3.3. Overall increase in awareness across agency about DD Overall increase in awareness across agency about DD issues.issues.
4.4. 100% more accurate case assignment.100% more accurate case assignment.
5.5. Improvement in frequency and timeliness of referrals Improvement in frequency and timeliness of referrals to detox and other APRA services.to detox and other APRA services.
Community ConnectionsCommunity Connections Intake Department Intake Department
Roshni Chatterjee, LPCRoshni Chatterjee, LPC
Director of IntakeDirector of Intake
202 608 4742/ 202 546 1412202 608 4742/ 202 546 1412
[email protected]@ccdc1.org
Suzanne Bechard, LICSWSuzanne Bechard, LICSW
Intake Coordinator for Children and Intake Coordinator for Children and AdolescentsAdolescents
202 548 4890 /202 546 1512202 548 4890 /202 546 1512
[email protected]@ccdc1.org
Sarah Ahmed, LICSWSarah Ahmed, LICSW
Intake clinician and PsychotherapistIntake clinician and Psychotherapist
202 546 1512202 546 1512
[email protected]@ccdc1.org
Caroline Quezada, LICSWCaroline Quezada, LICSW
Intake clinicianIntake clinician
202 546 1512202 546 1512
[email protected]@ccdc1.org
Kirsten Winters, LICSWKirsten Winters, LICSW
Intake clinician and PsychotherapistIntake clinician and Psychotherapist
202 546 1512202 546 1512
[email protected]@ccdc1.org
Victoria SherkVictoria Sherk
HIV and Wellness programHIV and Wellness program
202 546 1512202 546 1512
[email protected]@ccdc1.org