Appendix 2: Position Papers
Appendix 2: Position Papers
TAMHO
Tennessee Association of Mental Health Organizations
Tennessee Association of Mental Health Organizations
Co-Occurrence of Mental Health and Substance Abuse/Addiction Disorders
The Tennessee Association of Mental Health Organizations (TAMHO) supports efforts to improve the provision of behavioral healthcare for persons with co-occurring mental health (MH) and substance abuse or addiction (SA/A) disorders. A comprehensive, integrated and well coordinated system of care benefits all persons with service needs and especially benefits the significant percentage of persons with co-occurring SA/A and MH disorders (estimates range from 50-80%). Given that approximately 89% of persons with co-occurring SA/A and MH disorders experienced the onset of mental illness first[1], a system of care that optimally integrates mental health and substance abuse/addiction treatment is critical.
Furthermore, TAMHO member provider agencies assert that in order to develop truly integrated systems of care, funding mechanisms must allow for, and support, an integrated treatment approach that addresses both mental health and substance abuse/addiction disorders concurrently. Other barriers, such as conflicting facility licensure rules and processes, must also be addressed in order for provider agencies to fully develop integrated systems of care for persons with co-occurring disorders.
Again, supporting efforts to improve the provision of care for persons with co-occurring disorders is a priority for TAMHO member agencies. And, TAMHO applauds the commitment members of the DDRN Task Force on Co-Occurring Disorders have made to improve such systems of care.
Moccasin Bend Mental Health Institute
100 Moccasin Bend Road
Chattanooga, TN. 37405
Moccasin Bend is a 172 bed psychiatric hospital consisting of ninety-one (91) Acute Care beds and eight-one (81) Subacute beds for adults. The Institute serves a 23 county area extending north to the Kentucky border. Four community mental health centers'Fortwood, Hiawassee, Joe Johnson and Plateau'serve as the primary feeder facilities to the Institute and provide outpatient aftercare services to discharged consumers.
During the most recent quarter beginning October 1,2001 to December 31,2001 and from January 2002 to present, 40% of the hospital's average daily admissions have been dually diagnosed with co-occurring disorders. While the Institute is not certified to provide substance abuse treatment, a number of these individuals require detoxification and stabilization of symptoms. The hospital does not provide bona fide substance abuse treatment beyond stabilization of symptoms. Because the Institute is not certified for substance abuse services, trained staff is also not in place to provide such treatment and deliver the necessary specialized services. The vast majority of this population requires short-term stabilization of symptoms with longer-term substance abuse treatment indicated. The recidivism rate is significantly high among this population due in part to the absence of longer-term treatment. The Council on Alcohol and Drug Abuse Services (CADAS) is the primary resource for referrals of patients needing longer-term residential treatment. Bed availability at CADAS is limited due to the variety of community providers feeding referrals to this agency, including other medical and psychiatric inpatient units at Valley Psychiatric, Erlanger Medical Center, Parkridge, Eastridge and Memorial hospitals.
Limited residential treatment resources have a significant impact on the Institute and community, resulting in longer hospital stays while awaiting bed availability at CADAS, Reality House'a halfway house in Cleveland, or residential treatment facilities outside the Region 3 catchment area, most often in Knoxville and Nashville. In effect the Institute becomes a holding facility, simply maintaining and housing these individuals --- many with no place to go until a bed becomes vacant.
As a result of the substance abuse, many have lost jobs and housing, resulting in homelessness; many have burned all their bridges and no longer have social support systems; many become aggressive and violent secondary to the substance abuse and exacerbation of the illness; many end up in the criminal justice system due to public drunkenness, disorderly conduct, trespassing, or conflicts and altercations with others, including the police; many end up dead; many come to rely on the service system to provide the necessary supports and to meet their needs.
On the front end, the number of admissions to the RMHIs might be significantly reduced were their mechanisms in place for triage and crisis stabilization of this population. Once stabilized, further evaluation would determine if further treatment and care are indicated and refer accordingly thus reducing the demand for in-patient stays and freeing up more Institute beds for the SPMI population. One such unit is in the planning stage by Volunteer Mental Health Care System with an anticipated start date by June 2002.
Helen Ross McNabb Center, Inc.
Patricia A. Hall, Vice President
Helen Ross McNabb Center, Inc.
1520 Cherokee Trail
Knoxville, Tennessee 37920
The Helen Ross McNabb Center, Inc. (HRMC) has 54 years of experience working with residents of our community who have both mental illness and substance abuse issues. A merger between HRMC and the detoxification rehabilitation institute in 1997 brought a wider range of treatment possibilities into focus. Although this merger has, in and of itself, been quite successful, professionals in our organization have continued to be frustrated by the difficulties and barriers we have experienced in developing a structured treatment program, different than what we had in either AOD or mental health, to serve this population. Some of the barriers follow:
1. Treating the dual diagnosed is difficult.... According to Dr. Clifford Tennison, Chief Medical Officer at McNabb - it is the most difficult challenge facing mental illness professionals at this time. New drugs have enabled many of the difficult disorders, i.e. schizophrenia and others, to be more readily controlled. However, there is none of that for co-occurring disorders. A (person with) borderline personality disorder and a co-occurring substance abuse disorder is, again according to Dr. Tennison, a predictor for the poorest outcomes possible - suicide rates climb in this population and symptom complications worsen.
2. Dual disorders pose a terrible complication when treating children, whose symptoms are irregular and difficult to diagnose to begin with.
3. The great majority of persons in the Knox county jail system have complications due to substance abuse and mental health illness' in co-occurrence. HRMC conducts all the court ordered forensic evaluations in the Knox County Jail and, although we do mental health and AOD screening, we know that many fall through the cracks in getting the help that they need.
4. Dual diagnosis treatment is difficult for providers, i.e. the two types of diseases require different training, different values and currently must access separate funding sources.
Our efforts at McNabb to treat this population have not been as extensive or successful as we had originally envisioned. Although we have the components of a successful program, we have run into one major problem; that problem is the availability of adequate psychiatric time. Under TennCare, the valuable time of our doctors is often over used and not paid for if the AOD person is not on TennCare.
Mixing the different client populations has not proved successful either. Mental health consumers are not always comfortable in an AOD setting and vice versa. We have lacked the resources to establish a separate co-occurring treatment facility. It has not bee realistic to expect an already exhausted, under funded system to add the extra initiative needed to make this type of programming successful.
Tennessee has taken some steps to address the above-mentioned difficulties. Training supported by both the department of health and the department of mental health has been significant. What there hasn't been from the state departments is an organized and systematic effort to address the funding and resource issues.
From our experience, we believe a dedicated program is required. One that has a separate funding source, different monitoring, specific over sight, specific core competency requirements, and designated standards of care. We believe dual diagnosis programming should be a specific form of treatment, as is residential care, case management, detoxification, etc. Sequential treatment does not work for such a debilitating disorder. A framework and structure need to be developed and supported at a state level.
Without the needed level of support, agencies such as ours will continue to struggle with offering co-occurring treatment with overwhelming demands for our already existing system, whether it be mental health or substance abuse -- and will, therefore, fall short of our goal of serving a specific dual diagnosed population of consumer.
The Region III Provider Task Force on Co-occurring Disorders
The Identification and Treatment of Co-Occurring Mental Illness(es) and Addictive Disorder(s) A Perspective from Region III
Situational Analysis
Major stakeholders in the provision of treatment services for the mentally ill or persons with addictive disorders in Region III have learned the benefits of collaboration and connectivity. Current stakeholders include: AdvoCare of Tennessee, Tennessee Department of Mental Health and Developmental Disabilities, Moccasin Bend Mental Health Institute, Valley Behavioral Health Care System and Valley Psychiatric Hospital, Pine Ridge Treatment Center at Cleveland Community Hospital, A.I.M. Center, Fortwood Center, Council on Alcohol and Drug Abuse Services (CADAS), Comprehensive Community Care, National Alliance for the Mentally Ill (Tennessee) and Volunteer Behavioral Health Care System.
Collaboration by this group has resulted in:
1. The development of comprehensive housing services for high risk/high needs persons with severe and persistent mental illness (SPMI).
2. Sharing of resources, e.g., if a case managed consumer from Fortwood Center needs a supported living facility placement and the only one available is at a Johnson Mental Health facility, the Fortwood consumer gets the placement and maintains case management at Fortwood. This promotes continuity of care and meeting needs of consumer.
3. Major reduction in number of long term care consumers at Moccasin Bend Mental Health Institute.
4. Strategic planning in addressing co-occurring mental illness and addictive disorders treatment needs in Region III.
Collaborators began to formally address the impact of co-occurring mental illnesses and addictive disorders in July 2001. Following are the findings, recommendations and the current status of projects in Region III impacting services for persons with co-occurring mental illnesses and addictive disorders.
Findings
1. Significant data exists identifying the extent of co-occurring mental and addictive disorders. The generally accepted estimate in the United States is 10-12 million. Extrapolated to Tennessee, the estimate is approximately 240,000. Extrapolated to Region III, the estimate is 34,000. Anecdotal estimates are that 30-50% of Mobile Crisis contacts and acute psychiatric care recipients are persons with co-occurring illnesses.
2. Treatment providers have identified high risk/high needs consumers with either extensive or frequent acute psychiatric episodes as persons with co-occurring mental and addictive disorders.
3. Region III is primarily rural in nature, consisting of 23 counties in east central Tennessee ranging from the North Carolina, Georgia and Alabama borders to Kentucky. The majority of mental and addictive disorders services are in the Hamilton and Bradley Counties areas with a limited availability in the Putnam County area of the Upper Cumberland. Historically there has been limited coordination of services for co-occurring illnesses by providers in the region. Most services are for the adult population.
4. The Region III Mental Health Planning Council has historically identified the need and recommended comprehensive treatment services for persons with co-occurring mental and addictive disorders.
5. Persons with co-occurring disorders frequently have extensive law enforcement contact and are at high risk of incarceration.
6. Limited housing options exist for persons with co-occurring illnesses due to criminal history and/or history of drug involvement while residing in public housing, supported living facilities, boarding homes, etc.
7. Numerous treatment professionals fail to assess for, identify, and/or treat co-occurring disorders.
8. Assessment strategies and instruments are available to assist in determining whether a co-occurring mental and addictive disorder exists or not, e.g., Comprehensive Addictions and Psychological Evaluations (CAAPETM); Practical Adolescent Dual Diagnosis Interview (PADDITM).
9. The strategy for determining the priority adult population (SPMI) in Tennessee (CRG) does not include impact of addictive disorders.
10. Treatment providers primarily utilize asilo approach' to treating mental illness and addictive disorders in Region III. The delivery system exemplifies the parallel and sequential approaches. Research shows integrated treatment vastly improves recovery potential. Comprehensive Community Care (CCC) provides a SMISA (Severely Mentally Ill Substance Abusing) service consisting of outpatient psychiatric care, case management, alcohol and/or drug counseling and other supportive services in an integrated model.
11. Funding streams for treatment services do not facilitate development of co-occurring services generally reflecting thesilo' approach previously discussed.
12. There are limited community support groups for persons with co-occurring mental and addictive disorders.
13. Mental Health treatment providers utilize medical necessity to determine treatment intensity while addictive disorders treatment providers use the American Society of Addiction Medicine (ASAM) criteria.
14. There is no formal on-going training initiative to train a cadre of providers in the integrated care model.
Recommendations - General
1. Educate Federal, State and Regional stakeholders on extent of co-occurring mental and addictive disorders and need for integrated service delivery system.
2. Development of strategic plan for the implementation of comprehensive treatment services for co-occurring mental and addictive disorders in Tennessee utilizing an evidence based integrated model.
3. Development of a comprehensive and on going training system on integrated care of co-occurring disorders for providers/treating professionals.
4. Development of service funding strategies recognizing nuances of treating persons with co-occurring mental and addictive disorders. For instance, funding mechanisms need to permit the Tennessee Department of Mental Health and Developmental Disabilities along with the Tennessee Department of Health Bureau of Alcohol & Drug Abuse Services to address services for co-occurring illnesses.
5. Seed community support groups for persons with co-occurring illnesses.
Recommendations Region III
1. Regional acceptance ofco-occurring' illnesses by providers and advocates
2. Crisis Stabilization unit(s) capable of serving persons with co-occurring disorders.
3. Medical detoxification services sensitive to co-occurring disorders.
4. Long term residential treatment for persons with co-occurring disorders to be used in conjunction with acute and subacute care.
5. Supervised Residential/Halfway for persons with co-occurring disorders.
6. Development of housing options specifically targeting needs of persons with co-occurring disorders.
7. Case Management services for persons with co-occurring focus:
a. Expand SMISA in Hamilton County
b. Pilot CTT in rural area serving people with co-occurring conditions
8. Pilot a regional comprehensive treatment continuum of care for persons (adults and adolescents) with co-occurring illnesses.
Note: Region III recommendations initially developed during July 2001 Region III Assessment of Services for Persons with Co-Occurring Mental Illness and Addictive Disorders. Participants were: Michelle Bostwick, Fortwood Center; Gloria Bulloch, Moccasin Bend Mental Health Institute; Chandra Fears, formerly with AdvoCare of Tennessee; Pat Fitzpatrick, formerly with Valley Psychiatric Hospital; Joel Klein, Cleveland Community Hospital; Linda Loy formerly with CADAS; Melissa Wilson, Comprehensive Community Care; and Dan Smith and Jerry Jenkins of Volunteer Behavioral Health Care System
Status
1. Walk-in/Police Diversion Center opened by Volunteer Behavioral Health Care System in December 2001 as part of comprehensive service continuum for persons with mental illness/co-occurring mental and addictive disorders. Stakeholders include Tennessee Department of Mental Health and Developmental Disabilities, AdvoCare of Tennessee, Hamilton County Sheriff's Department, Chattanooga Police Department and Erlanger Health System.
2. Crisis Stabilization Unit being developed in Hamilton County by Volunteer Behavioral Health Care System with capacity of serving persons with co-occurring disorders. Stakeholders include Tennessee Department of Mental Health and Developmental Disabilities, AdvoCare of Tennessee, Hamilton County Sheriff's Department, Chattanooga Police Department, Erlanger Health System, National Alliance for the Mentally Ill (Tennessee), Moccasin Bend Mental Health Institute, Valley Psychiatric Hospital, CADAS, Fortwood Center and Comprehensive Community Care. Operational date is projected to be June 2002.
3. Medical Detoxification Services Cleveland Community Hospital and Valley Psychiatric Hospital are currently providing services for persons with co-occurring illnesses. The Crisis Unit being developed by Volunteer will add ambulatory capacity for detoxification services for persons with co-occurring illnesses.
4. Residential Services for Co-occurring Disorders Volunteer Behavioral Health Care System, in collaboration with the Tennessee Department of Mental Health and Developmental Disabilities, AdvoCare of Tennessee, National Alliance for the Mentally Ill (Tennessee), Moccasin Bend Mental Health Institute, Valley Psychiatric Hospital, CADAS, Fortwood Center and Comprehensive Community Care, is pursuing implementation of a Residential Treatment facility in Region III.
5. Housing The CHI Creating Homes Initiative of the Tennessee Department of Mental Health and Developmental Disabilities is pursuing housing options for persons with co-occurring disorders. Specific emphasis is being placed on having resources for persons with co-occurring disorders who previously have a criminal history. Stakeholders include Moccasin Bend Mental Health Institute, CADAS, Volunteer Behavioral Health Care System, Fortwood Center, Chattanooga Housing Authority and the A.I.M. Center.
Respectfully submitted by:
Jerry A. Jenkins, M. Ed., LADAC, MAC
Vice President, Area Operations (Southern Tier)
Volunteer Behavioral Health Care System
Knox Area Rescue Ministries
Gabrielle Cline
Director or Client Services
Knox Area Rescue Ministries
865.673.6550
At Knox Area Rescue Ministries, we see a large population of people with co-occurring disorders in our residential programs for men, women and families and in our overnight programs for men and for women. For approximately 30% of the people in our residential programs (about 103 people in 2001*") and an unknown number of people in our overnight programs, the combination of mental illness and addiction has played a significant role in becoming homeless.
There are many barriers to helping this population. First, it is extremely difficult to obtain an accurate diagnosis. Many of our clients are quite transient and receive services from our shelter on an inconsistent basis. In addition, many of the mental illnesses they suffer from present a challenge to engaging the client and establishing a helping relationship. The fact that most of our clients lack access to adequate physical and mental health care is yet another barrier. The most recent study of the homeless in the Knoxville area, Homelessness in Knoxville/Knox County: 2000 found that 49% of our clients (or about 1724 people) have no access to health insurance (Nooe, 2000). These clients must, therefore, rely on the Health Department or hospital emergency rooms for their medical and psychiatric care. Around 14% (493 people) report receiving no health care whatsoever in the past year (Nooe, 2000). The 51% of our clients (1794 people) who do have TennCare (Nooe, 2000) have great difficulty locating providers for mental health or addiction treatment, let alone providers who specialize in the treatment of co-occurring disorders/dual diagnosis.
A problem we face frequently with our overnight population is a lack of viable options when we are unable to serve them. When we cannot safely contain a person due to out-of-control behavior (frequently the direct product of their co-occurring disorders), we have very limited options. The best current option is to contact the Mobile Crisis Unit to seek admission to a psychiatric facility. However, this can only be done if the client is a threat to self or others. If the client does get admitted to a psychiatric hospital, they are frequently treated only briefly (and often only for the mental illness) and then released. For the homeless population, the chances of adequate follow-up with the discharge plan are low. The only other option for a person we cannot safely serve is to contact the police who may either take the person to jail or simply escort them off the property. Neither of these options connects people with services that will help treat their co-occurring disorders.
There is also a great need for both transitional and permanent supportive housing for our clients with co-occurring disorders. Many of our clients face difficulties when they complete our residential program. While they may have achieved recovery and function well in our setting, they are at high risk for relapse when asked to move out on their own. However, there is a lack of transitional housing to help them ease into independent living while still receiving support. Yet another segment of our dually diagnosed population is in need of permanent supportive housing in order to maintain their recovery and function at their highest level. In this area, too, there is a lack of resources.
The issue of developing adequate resources for those with co-occurring disorders becomes that much more important when we consider the impact on children. Approximately 50% of dually diagnosed clients in our residential program have children. Some of these children have been placed in foster care due to the parents' inability to care for them. Other children have suffered from a mother or father who has not been involved in their lives due to the parent's dual diagnosis. And still other children are currently spending important childhood years in a shelter setting while their parents attempt to recover to a point where they can live independently and adequately take care of their families.
In summary, the lack of adequate resources for dually diagnosed individuals has a large and detrimental impact on the homeless population. Such clients often go undiagnosed and, when they are diagnosed, have difficulty accessing adequate treatment. There are a limited number of providers in the community that address both the client's mental health issues and substance abuse issues. In addition, there are few options in terms of emergency care for this population. For dually diagnosed clients who do reach a level of stability in their recovery, there are few support services that will allow them to live independently (when this is possible) or in a supportive environment that will allow them to minimize the number of re-hospitalizations and relapses. In creating services for the dually diagnosed, it is important also to include those outside of the typical mental health arena (such as law enforcement, hospitals, and shelters) in planning and policy decisions.
* All client numbers are from 2001.
Nooe, R. M. (2000)Homelessness in Knoxville/Knox County: 2000', Knoxville:
Knoxville Coalition for the Homeless.
Peninsula Behavioral Health Position Paper
Co-occurring Psychiatric Illness and Substance Abuse / Chemical Dependency
Who we are:
Peninsula Behavioral Health is comprised of Peninsula Hospital, an acute care psychiatric facility; Peninsula Village, a residential program serving adolescents; Peninsula Lighthouse, which provides partial hospitalization and intensive outpatient services; and Peninsula Outpatient Centers, which provides community mental health services. These community services include individual, group and family therapy, medication management, mobile crisis services, case management, psychiatric rehabilitation, supported employment, supported housing, drop-in centers and alcohol and drug treatment services. This continuum of care serves children, adolescents and adults. Peninsula Behavioral Health is a non-profit member of the Covenant Health System, a healthcare delivery organization headquartered in Knoxville, Tennessee. Services include acute care hospitals, outpatient facilities, and specialized care in areas such as cancer, rehabilitation, physician and specialty clinics, and home care. Covenant Health includes approximately 1,500 licensed beds, approximately 8,000 employees and about 1,700 affiliated physicians.
Barriers to Treating Co-occurring Illness:
Peninsula Behavioral Health is an integrated system of care that combines elements of both mental health and addiction treatment into a unified and comprehensive treatment program for our patients. In treating co-occurring illness and chemical dependency or substance abuse, two themes emerged as problems or barriers to successful treatment. These issues are funding and education / staff training.
The issue of funding has many aspects that affect the treatment of co-occurring disorders.
' The cost of treatment is high. Patients with co-occurring disorders incur significantly higher healthcare costs than patients with a single disorder. Emotional and physical stability are always compromised by addiction, as is compliance with medical and mental health treatment.
' Length of treatment is increased with co-occurring disorders as the patient receives concurrent treatment of both illnesses.
' Reimbursement restrictions placed by third party payers also adds a heavy burden to both the patient and the agency trying to integrate care.
The second issue that continues to be a barrier to the treatment of co-occurring disorders and chemical dependency is one of staffing / education. Hiring staff who are competent and dedicated to the unified and comprehensive philosophy of co-occurring illnesses is difficult. Staff typically falls into one of two categories: those who are trained to treat chemical dependency or those who are trained to treat mental health issues. Current research has not determined a best approach that has proven to be successful with all individuals. Therefore, competence of staff to provide treatment interventions from both perspectives has the potential for producing optimum results for the client.
