The Expansion of The Capacity of A Transitional Living Facility

• Contract Information
• Dates of Service: October 1, 1998 through September 30, 2001
• Grantee Federal
• Identification Number: 5 H79 TI11571-03 (B&D ID #010)
• Project Name: Expanded Capacity of a Transitional Living Facility
• Principal Investigator: Pam Sylakowski
• Evaluator: Thomas W. Doub, Ph.D.
• Project Location: Foundations Associates; Nashville, Tennessee
• Michael Cartwright, Executive Director

Project Purpose

Transitional Living’s aim, sponsored by SAMHSA’s Center for Substance Abuse Treatment (CSAT), was to assess the primary and secondary effects that included an integrated continuum of care for people with co-occurring mental health and substance abuse diagnoses. The project will evaluate efficacy in the primary outcome domains of drug abuse, mental illness, and cost-effectiveness, with each domain being assessed using multiple sources of data. The evaluation participants participated in a three-part instrumentation package designed to estimate the trajectory of change in detail as measured by transitional Living. To reduce measurement error, the project used multiple data sources in statistical modelling and used a longitudinal design to track progress. In all, 144 people were to take part in Transitional Living over a three-year cycle, with data collected at three points for each participant (baseline, six months, and twelve months).

Background/Implementation of the Project

In 1995, Foundations Associates, which runs the Project site, was formed as an integrated network to treat mental health and substance use disorders co-occurring in Transitional Living. While the project’s core programmatic principles were already in place at this location, the hybrid nature of the project created challenges in maintaining programs within the existing treatment environment, which adopted single-state organization, single-diagnosis care models. The established Foundations program was operating with one 8-bed facility at the grant award. There was no public sector funding mechanism available for a fully integrated residential service model such as Transitional Living. The project will encourage the organization to broaden its female services and align its continuum of care more closely with the American Society of Addiction Medicine’s Patient Placement Criteria, Second Edition (ASAM-PPC-II).

The project was scheduled to start on September 30, 1998. Budget approval delays (i.e., the State authority’s inability to approve project execution before the formal CSAT budget approval) pushed the start date back to January 1, 1999.

Additional Obstacles to Adoption Included:

• Ensuring a “fit” within the current framework.
• Legitimizing the need for dual diagnosis services among both providers and payers.
• Educating the local community about the discrepancies between an integrated versus sequential or parallel service model.

Despite state licensure requirements hindering the project’s ability to fill open beds early in the implementation process, for example, Transitional Living, state requirements hindered the project’s ability to fill empty beds.

Due to the substance abuse portion, the Division of Mental Health (DMH) initially denied licensure and delegated Foundations’ management to the Bureau of Alcohol and Drugs. Although less worried than the DMH division about the dual status of the population, the Alcohol and Drug division mandated commercial zoning for licensure. Foundations was ordered to return to DMH to obtain licensure status because the transitional living facility was residentially oriented. Although licensure was eventually obtained through DMH, it took about a year after the efforts began and required a lot of education and lobbying. Fortunately, those efforts started prior to the project’s competitive award. It’s worth noting that there are currently no dual diagnosis licensing bodies in the state.

The following is a rundown of main incidents that occurred within the first six months of implementation:

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Foundations sought an additional $497,800 in funding in May of 1999 to complement the assessment and programming budget for Transitional Living during the two remaining years of the contract. Funds from the assessment were used to employ a part-time interviewer and reward customers who took part in follow-up assessments. Programmatic funds were requested to cover a portion of the clinical director’s and psychologist’s hours and other supplies and equipment. The funds have been authorized for Transitional Living.
The project gained traction in the community, and admissions soared in the third and fourth quarters. Ten out of 26 accepted customers withdrew from Transitional Living programs due to staff turnover during the third quarter. Staff preparation and identifying and standardizing the approach to integrated services were given a lot of attention as the staff’s size and complexity grew. Participants in the Transitional Living program learned strategies to improve motivation and adaptability. DiClimente’s stage-wise approach and psychopharmacological therapies also were discussed. The following activities were introduced during the second six-month period:

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With an average age of 35.7 and a range of 20-59, admitted consumers were 50 percent male, 19 percent African American, 73 percent Caucasian, and 8% other. Sixty-nine percent recorded alcohol use within 30 days of admission (54 percent to intoxication), and 62 percent reported use of illicit substances 30 days prior to admission, with cocaine/crack (46 percent), marijuana/hashish (35 percent), and benzodiazepines being the most widely reported drugs 30 days prior to admission (19 percent ). Prior housing and living conditions were characterized as stable by 62 percent of the consumer population in the 30 days prior to admission, while 27 percent were institutionalized and 12 percent were previously residing in shelters.

Operational Phase – Year Two

The service was fully operational by year two, and customers were being placed on a waiting list as the number of referrals continued to rise.

It Became Clear that There Was a Need to Concentrate Resources on Two Main Areas:

• Cross-training of technical and non-professional staff was essential to ensure that services remained completely “integrated.”
• While the community was supportive of a grant program to treat a “difficult to treat” population, community perspectives into integrated treatment, dual diagnosis, or the importance of funding had yet to emerge.

TCE funding enabled multidisciplinary health personnel such as doctors, psychologists, clinical social workers, and addiction counsellors to Transitional Living. However, clinicians’ ethical views on care were significantly different from those of Transitional Living. In preparation for Transitional Living, philosophical perspectives and treatment biases had to be addressed to derive strengths-based and client-focused components. During their transitional living training, mental health workers were taught 12-step philosophies, disease principles, relapse prevention, and abstinence.

Transitional living is also required of traditional alcohol and drug practitioners. They need to learn about psychotropic medications, their uses and side effects, empathy, listening skills, harm reduction theories and more. Motivational enhancement methods were taught to all employees, and they are still being taught. Before various disciplines could discuss dual treatment Transitional Living, it was clear that identifying varying philosophical viewpoints and ongoing preparation, education, and expertise was necessary.

Simultaneously, while emerging literature strongly endorsed integration activities, existing literature was construct- and theory-based and lacked concrete operational integration techniques. To that end, efforts focused on identifying and developing operational practices as part of the CSAT model program were made Transitional Living.

Through this project, Transitional Living, we gained insights into how philosophical tenets essential to traditional service systems are often incompatible with an integrated program’s mission. To make progress in this regard, organization efforts must strive to foster a modern culture that draws on the strengths of a variety of disciplines while promoting transitional living paradigms. Weekly staff training included non-confrontational, motivational therapy with damage reduction approaches for theory integration, facets of psychopharmacology, and Dual Recovery Anonymous.

In addition to the sustainability topic above, gaining community support for integrated services, Transitional Living, was based on raising community awareness. Although private-sector funding sources have been more open to innovative concepts and have responded to long-term effectiveness results, public-sector programs have been slower to embrace new delivery systems. Community outreach and marketing projects aimed to create awareness of the consequences of comorbidity and identify sources of funding to maximize the integration of care Transitional Living.

Foundations Associates launched a media initiative that included statewide and local conferences, publishing a co-occurrence newsletter, and developing a transitional living anti-stigma package. Several private contracts had been secured by the end of the second year. State Medicaid administrators, on the other hand, have not shown a willingness to pay for integrated residential care. Sustainability Transitional Living proved to be the most insurmountable obstacle to success. Through federal support for treating dual disorders through the Substance Abuse Mental Health Service Administration (SAMHSA), grant funding sources for individual states remained distinct and fragmented. Transitional Living remained a challenge for Tennessee’s state-based mental health and substance abuse programs, even after a Medicaid waiver merged mental health and substance abuse blocks grants.

The following were some of the major events that took place during the second year of operations:

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Alcohol, cocaine/crack, and marijuana were the most commonly used drugs by those served in year two. The most common diagnoses of Transitional Living were bipolar disorder and major depression with psychotic features. A personality disorder was diagnosed in more than half of the admitted customers. Customers at Transitional Living corresponded ethnically with Nashville’s ethnic breakdown.

Consumers registered a higher proportion of medical issues than clients in specific substance abuse services and job issues equivalent to those in most public facilities. Still, the facilities which Transitional Living operates far exceeded the average of most private facilities. Furthermore, customers identified more legal issues than clients in specific recovery services and more family and social programs. Transitional Living revealed significantly higher rates of psychological illness in consumer profiles when compared with traditional substance abuse recovery programs.

Operational Phase – Year Three

The third year of programs was dedicated to proactively approaching sustainability. There was evidence that community outreach programs at both the local and national levels resulted in greater knowledge about dual diagnosis Transitional Living. Preliminary outcome research suggested that program participants would have strong positive long-term results. Both local and national attention increasingly focused on co-occurrence as a major social problem and Foundations as a promising treatment model. As a result, public sector payers became more open to entertaining funding discussions. The Transitional Living program was expanded by Foundations Associates a month before the TCE grant expired. These, as well as other essential tasks performed during that period, are detailed below.

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Program Description

Since there was a lack of literature on methodologies for incorporating treatment, many works were put into operationalizing certain methods during Transitional Living. The following paragraphs define the evaluation, care, and staffing components that we believe are essential for effective treatment integration in connection with Transitional Living.

Assessment

The Foundations assessment model differs from other models in which primary assessment responsibility is delegated to many clinicians Transitional Living. The consolidated strategy ensures that a competent clinician performs evaluations in determining both the seriousness of drug use and the magnitude and type of co-morbid mental health conditions. Transitional Living was staffed with a single admissions advisor responsible for administering the core assessment materials used in clinical evaluation (and research), generating summary report criteria, and making necessary referrals for additional clinical evaluations, such as those by doctors at a psychiatrist psychologist, or other professional.

When Transitional Living was planned, the reliability and validity of new integrated evaluation protocols had not yet been defined for this population. Transitional Living’s tests were selected because they proved reliable and valid in communities such as those served by Foundations Associates, i.e., most people with substance abuse problems and severe mood disorders and thinking disorders. To mitigate the effect of biases on the clinician or the patient, the entire procedure included elements of both clinician-report and self-report. Transitional Living designed the basic evaluation kit with appropriate accommodations based on the consumer’s presenting needs, including the medical intensity, the reading level, special needs or disabilities, and cultural factors.

Non-Standard Protocols Were Created to Accomplish Two Goals:

• Implement ASAM PPC-IIR steps in order to make placement decisions simpler. The ASAM crosswalk was used, as well as the creation of basic requirements that established medical need levels for each stage of the Foundations’ continuum of care.
• To provide a forum for combining treatment components, give the psychiatric component of the assessment more complexity. An in-depth interview was conducted to learn about the consumer’s family of origin, mental health and drug abuse treatment history, recent traumas, behavioral patterns, medical symptomatology, and psychopharmacologic treatment history.

The Following Elements Were Included in The Evaluation

Pre-selection (completed by referring agency or administrative staff)

• Short Referral Form with a review of the patient’s diagnostic and treatment background
• The consumer completes Stages Of Change Readiness and Treatment Eagerness Scale (Miller & Tonigan, SOCRATES; 1996)

Intake Assessment

• Comprehensive Psychosocial Interview: Treatment history; multiaxial DSM-IV diagnosis assessment; mental status examination; evaluation of mitigating factors, such as social/family/peer problems, legal, cultural, moral, vocational, housing, crime, and other consumer-specific issues; information from collateral informants; Release of Information; eligibility for public assistance).
• Standardize assessment battery: Brief Symptom Inventory (BSI), Addiction Severity Index (ASI), Personality Assessment Inventory (PAI) (Schizophrenia Subscale), Empowerment Survey, Quality of Life Inventory (Customized Lehman’s QOLI).
• American Society of Addiction Medicine (ASAM) PPC-IIR Multidimensional Assessment
• Initial Treatment Planning Recommendations

Psychiatrist Assessment

• Psychiatric interview and review of previous assessment materials
• Diagnostic Impressions (multiaxial DSM-IV)
• Need for pharmacotherapy
• Assessment of acute intoxication/withdrawal risk
• Evaluation of comorbid medical conditions
• Review of Treatment Planning Recommendations

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 collaborative services
• Referrals for additional assessment as needed

Through the Transitional Living assessment process, the consumer’s suitability for Foundations’ integrated residential program, key health issues, and individualized treatment strategies were assessed. The required referral was expedited if a consumer was considered a bad match for Foundations’ residential program (due to a single condition, a poor fit for individual treatment needs, or a recommendation for another level of care).

The staff training states that assessment is often the first opportunity for an organization to get involved with the consumer and begin constructive therapeutic collaboration with Transitional Living. As a Transitional Living Program intake assessment staff representative, staff were encouraged to develop an immediate positive rapport with the client and create trust and empathy. This is especially significant for services that serve customers with co-occurring disabilities, who are often treatment veterans since it demonstrates program sensitivity to customer needs (and motivational status) and sows the seed of hope for potential treatment efforts.

Clinical teams continuously assess consumers throughout their care, gathering information so they can adapt Transitional Living to their particular needs. It’s understandable that eliciting a detailed diagnostic overview and issue summary during a quick intake evaluation session where rapport must also be formed is difficult. In Transitional Living, continuous assessment is especially important due to the inherent complexity of identifying substance-induced and mental health conditions.

In terms of the sequelae of drug abuse, such as hallucinations, delusions, paranoia, and the like, transitional living is well known that these symptoms can reflect mental health disorders or vice versa. Only by reviewing historical data on consumption trends and related symptoms can a clinician make a definitive diagnosis of Transitional Living.

This is especially important if a person is seeking treatment for a substance use disorder but hasn’t been abstinent for an extended period of Transitional Living. To accurately differentiate the effects of drug use versus mental health symptomatology in his case, program personnel must closely track improvements in clinical condition following program entry. Therefore, it was stressed that clinical evidence was collected in the ongoing evaluation process and then incorporated into individual care plans, reviewed treatment objectives, monitored progress toward targets, and assessed consistently step-down and discharge goals Transitional Living.

Program Elements

An individual’s mental health, physical health, vocational/educational, financial, housing/life skills, spiritual, and recreational/social aspects were assessed during the admission process Transitional Living. A primary therapist was assigned to each person to help with care coordination. Based on their assessment, the individual was directed to Transitional Living based on whether they needed outpatient treatment. The elements of service are listed below.

Crisis Stabilization

Individuals at acute risk of inpatient clinical treatment are typically admitted to crisis intervention for a 72-hour stay to stabilize psychiatric or drug abuse symptoms and prescription changes. Transitional Living uses a combination of standardized residential and aggressive pharmacologic treatments to provide interim trauma care until the patient is stable Transitional Living. As necessary, Foundations connects consumers to community services, placements, or Transitional Living.

In crisis care, Transitional Living, on-call 24-hour medical and clinical staff, daily monitoring by a psychiatric nurse practitioner, ongoing psychiatrist assessments are also provided. Even though diversionary programs were not designed specifically to support dually diagnosed people, more than 60% of those who use them are. At-risk groups with co-occurring disorders are identified, and they are enrolled in non-traditional comprehensive programs Transitional Living. All remaining Foundations services serve only dual-diagnosed clients, the vast majority of whom have Axis I mood or perception disorders as well as co-occurring substance abuse.

Dual Diagnosis Enhanced Therapeutic Community (DDETC)

The Tennessee Department of Mental Health and Developmental Disabilities licenses eight-bed residentially based houses to provide the DDETC portion.

The Following Are Important Aspects of The Program:

• Length of stay: Depending on the severity of the symptoms and the patient’s use history and recovery progress in Transitional Living, a stay in the DDETC can last between six weeks and three months. The client may be referred to the foundations transitional living program at the end of the first phase of services, allowing them to transition from the Foundations’ housing continuum to community-based care, as defined both diagnostically and individually. Treatment objectives are combined with successful step work and milieu achievements Transitional Living to determine when and how advancement occurs.
• Staffing: The majority of the resident counsellors are mentors from rehabilitation and program graduates Transitional Living. They supervise staff 24 hours a day, seven days a week. A master level therapist is on-site during business hours, and each Sunday during visitation, a family therapist/educator is on-site. Transitional Living therapists work closely with the consumer and their families by scheduling individual appointments, family counselling, and establishing joint rehabilitation goals. During weekends, a weekend therapist leads an educational program focused on dual treatment dynamics, medication safety, and individualized reintegration strategies, emphasizing structure and support of Transitional Living. NAMI support groups allow families and support networks to join. The nursing staff at Foundations Associates and the area mobile crisis management team are available 24 hours a day, seven days a week, for crisis calls. Transitional Living’s group therapy/psychoeducation portion includes psychiatric assessments and psychopharmacological interventions for all customers. All workers are expected to use non-confrontational, motivational interviewing methods reinforced during orientation, training, and weekly clinical meetings.
• Psychoeducation/Therapy: The psychoeducation/therapy program is a comprehensive, integrated, dual treatment program through three regular groups lasting an hour each; each group focuses on psychoeducation, addictions treatment, relapse prevention, therapy, and strategies for Transitional Living. All the psychoeducation/therapy system modules are designed to educate and inspire recovery for those affected by both conditions Transitional Living. The implementation of DiClimente’s stage-wise method for determining care according to the individual’s readiness to adapt is the second principle, which is equally essential in an integrated regimen. Transitional Living combines cognitive therapy with motivational interviewing and a 12-step dual rehabilitation intervention Transitional Living prepare staff on non-confrontational ways of directing progress. Transitional Living patients are helped by a recovery team that includes physicians, psychologists, professional social workers, and licensed alcohol and addiction counsellors.
• Peer Mentors: At the time of entry, each customer is assigned a peer mentor. Peer mentors have met important personal rehabilitation milestones and are approaching the end of the first phase of therapy. The mentor’s job is to help with orientation, acclimation, and to have a positive outlook on recovery.
• Community milieu elements: From the start of the program and throughout, participants are expected to take on shared roles. The residents complete tasks such as cooking, washing, and other routine tasks with the assistance of staff who act as examples of Transitional Living. The degree of staff assistance is dictated by customer need, and when less educational assistance is required, staff members are expected to participate as members. Peer mentors are also primary educators.
• Peer Review Committee (PRC): In Transitional Living, harm reduction measures must be implemented even when the model promotes abstinence: community profile and an appreciation of various phases of rehabilitation results in this understanding and agreement. When a successful program participant relapses and wants to seek recovery, he or she must perform a Relapse Self Evaluation. Relapse Self Evaluation is a protocol that facilitates accurate trigger detection and preparation for relapse and assesses the effect of relapse on the person, their community, and their support systems Transitional Living. The member gives a public presentation of his or her evaluation and is rated by committee members based on previous motivational and commitment qualities and potential relapse prevention strategies. The committee’s task is to decide if the person should continue in care or should be referred to more conventional treatment options. Transitional Living has seen its customers and the wider community be significantly impacted by this mechanism’s influence on change and collective accountability. Following is a copy of the protocol, which incorporates elements recommended by the care group for inclusion in this process.
• Integrated schedule elements: The residential model combines rehab and treatment therapies, including diagnostic education, drug education and management, relapse prevention methods, and encourages participation in 12-step programs, especially Dual Recovery Anonymous Transitional Living. As with the outpatient model, both interventions examine the interrelatedness of comorbidity. Both use a variety of psycho-educational modules and didactic therapies utilized in tandem with Transitional Living. The community service includes drug education groups and medication monitoring.
• Progressive levels of privilege: In Transitional Living, decision-making is based on psychological health, progress through the DRA rehabilitation program, achieving treatment goals, and various other factors. The members are put under the obligation to reinforce their own commitments, as well as those of Transitional Living.

Entry Level

Entry-level is a transitional living orientation process that helps the user to become acquainted with the staff, occupants, and structure of the facility. The primary therapist schedules consumer demands for meetings with relatives, initial case management needs, and doctor’s appointments.

Level 1: Intensive Residential Phase

Individual weekly therapy is also part of the Level 1 recovery process. Residents in Transitional Living are encouraged to participate in weekly trips and support group meetings off-campus. The consumer may progress to Level 1 if the clinical treatment team (which includes the Housing Coordinators, Clinical Director, Psychiatrist, and Psychologist) has decided through case analysis that the consumer has successfully met Entry Level requirements. Transitional Living marks the beginning of the consumer’s return to self-sufficiency until he or she becomes self-sufficient.

Level Two: Intermediate Residential Phase

During this point, Foundations’ staff assists the client in learning independent living skills and taking greater responsibility for his or her own rehabilitation.

Level Three: Transitional Phase

When a consumer is elevated to this phase, it means the clinical care team believes the consumer has completed Foundations’ Intensive Outpatient Program successfully.

Level Four: Community Reintegration Phase

Promotion to Level Four suggests that the customer is regularly exhibiting integrity and a sense of duty toward themselves and others, as defined by the clinical care team and the consumer.

Level Five: Independent Living

The commitment to rehabilitation and personal development is the hallmark of a Level Five recipient Transitional Living. The level of a person who participates actively and passionately in the 12-Step recovery program frequently and exhibits integrity and accountability to himself or herself and to others Transitional Living indicates that he or she has consistently taken responsibility for all aspects of his or her rehabilitation.
Besides peer reviews and house meetings, Transitional Living also uses individual therapeutic interactions and assessments to measure progress. Increased psychological symptoms, relapse, increased environmental stressors, or rule violations may result in level regression. Most level change decisions in Transitional Living involve both the care team and the community.
An individual’s participation in the Foundations’ continuum of care after the first six-eight week period of intensive treatment is based on service access and medical requirements in Transitional Living. Medically suitable individuals for continued care Transitional Living usually have an inpatient history of psychological and substance abuse treatment, cannot maintain long-term sobriety, and present in high-risk settings. During Transitional Living’s final two weeks of intensive treatment, the team strives to strengthen natural and structured support structures and actively facilitate reintegration readiness. After intensive treatment, both customers who live in Foundations’ housing are eligible to enrol in the Aftercare program. Interested program participants are urged to participate in aftercare activities, including big-book research, recreational events, and work on reintegration problems that generally affect individuals with dual diagnoses of Transitional Living.

Dual Diagnosis Enhanced Halfway House (DDEHH)

The DDEHH facilities are built to meet the resident’s needs and are easily accessible. Transitional living and other non-residential services are available, including individual, family, community, and counselling. DDEHH services are given in 5-bed houses approved by the Department of Mental Health and Developmental Disabilities and situated within blocks of DDETC housing and last from 2-4 months. Foundations Associates clinical staff is available 8 hours a day, with a 24-hour crisis call service offered by the regional mobile crisis response team. Transitional living provides staffing for 24 hours per day.

For a successful transitional living program, consumers must check in every time they arrive and leave the residence. A master level Independent Living Housing Coordinator works closely with and user in this level of care to establish and resolve expectations and reintegration preparation. In our program, the emphasis is on life skills, personal responsibility, independence, and transitional living. A vocational specialist works with all consumers to meet a wide range of vocational educational needs, from resume development and career search planning to direct skill teaching through a supportive employment plan.

Participants create an individualized Therapeutic Contract that specifies financial/rental arrangements for Transitional Living and community, individual, and financial objectives. There is no treatment cost for this standard of service, but consumers must be competitively working and pay market-rate rent. This arrangement covers all food and services.

Dual Diagnosis Enhanced Independent Living (DDEIL)

The Foundations continuum ends with supervised independent Living. Transitional Living makes decisions about program services based on individual agreements with the Foundation that establish a group’s, individuals’, vocational, and financial priorities. The consumer is responsible for arranging community programs, psychiatric appointments, prescriptions, and other needs, and therapy sessions are limited to monthly or bimonthly encounters. Transitional Living requires you to participate in aftercare. The average length of stay in DDEIL housing is 2-4 months. Consumers must be competitively employed and pay market-rate rent, much as in the halfway house. This arrangement includes food and services as part of the Transitional Living Program.

Principles and Course of Treatment

SAMHSA designated Foundations Associates’ residential program as a model project for integrated Transitional Living treatment. The residential services were recently named a finalist for the American Psychiatric Associations’ (APA) Gold Achievable Program Award. As part of the residential treatment program’s treatment plan Transitional Living, Transitional Living provides case management, psychopharmacological care, vocational counselling, psychoeducation, individual and group therapy, 12 step interventions, and 12-step therapy.

The Program’s Concept Is Based on Seven Main Elements that Minkoff Identifies as Inherent in An Integrated Model of Care:

• Comorbidity Is the Standard, Not the Exception: Foundations Associates has primarily served the high-intensity SPMI/substance dependence demographic. Transitional Living estimates that a majority of consumers have undergone multiple mental health and substance use episodes before entry. Pacing care according to individual needs was recognized early on as a critical component. Transitional Living often includes educational components to address post-withdrawal or subacute symptoms. Individual instructional and care components are brief, repeat topics regularly, and reinforce treatment of the consumer at his or her cognitive comprehension level. Transitional Living’s continuum of programs, case management, rehabilitation, 12-step methods, and psychopharmacology were also included. Although the aim was to hire skilled people in integrated theories, integrated skills were quickly discovered to be in short supply. As a result, all workers must participate in dual recovery training, seminars, conferences, educational forums, and other activities. Similarly, the team alternates presentations about current treatment approaches to comprehensive care in weekly meetings Transitional Living. All workers can access information from the Dual Diagnosis Recovery Network (DDRN), a library that acts as a national archive for dual diagnosis studies.
• Most Significantly, Successful Treatment Necessitates the Development of Warm, Empathetic, Hopeful, and Ongoing Treatment Relationships, in Which Coordinated Treatment and Care Management Are Maintained Over Multiple Treatment Episodes: All aspects of the program emphasize staff/client relationships in a friendly, non-punitive environment. An assessment is conducted, new treatments are developed based on the measures considered primary, dual rehabilitation is discussed, and the individual is assessed for their willingness to improve Transitional Living. Instead of imposing conventional treatment targets, staff were instructed to create client-driven care plans. Generally, relapses and decompensation are seen as an inevitable part of the pathology of the disorders, and efforts are made to intervene as soon as possible following such events as Transitional Living. These episodes are used to increase user introspection about relapse and decompensation causes and symptoms, and they are explored in group meetings and individual counselling sessions. Rather than relying on conventional approaches, attempts are being made to build services that address customers’ needs with dual diagnoses. For the complex dually diagnosed user, accommodation, for example, is often a difficult service to obtain. For someone who is a complex dual diagnosed individual, obtaining accommodation as a Transitional Living service, for example, maybe a challenge. Foundations mobilized consumer advocates and offered financial assistance to establish cooperative housing based on Oxford residential models. There were inadequate resources to position consumers the following care in the continuum. Also, collaborations with community-based programs were developed to target housing resources specifically for Foundation’s population Transitional Living.
• Case Management and Caretaking Must Be Balanced with Empathetic Detachment and Conflict in The Sense of The Continuous Comprehensive Therapeutic Relationship, Depending on The Individual’s Level of Functioning, Impairment, and Capacity for Treatment Adherence: In addition to demanding recovery preparation, transitional living plans compromise standard normative mental health caretaking and substance abuse empathetic detachment. Daily team evaluations of the individual’s progress in recovery result in ongoing modifications to treatment plans. Transitional Living In the early stages of recovery, much effort is focused on stabilizing clinical symptomatology and controlling cravings and withdrawal symptoms. As a result, the first two weeks usually see a higher degree of case management and caretaking efforts. If the patient’s ability to guide the direction of care improves, the onus increasingly returns to the consumer. Transitional Living changes the structure of the relationship based on level structures, concentrating on symptoms and withdrawal management. Level programs have an earned system of rights that determine when and how advancement happens by combining care objectives with successful phase work and milieu achievements. During house meetings, both the counselling team and the client base evaluate the effectiveness of Transitional Living.
• when Mental Illness and Drug Abuse Coexist, All Conditions Should Be Treated as Primary, and Integrated Dual Primary Care Should Be Used: Psychopharmacologic treatment requiring aggressive supervision and rehabilitation principles such as sober, structured housing, and DRA Transitional Living is the cornerstone of a co-primary care plan. Given the severity of the patients at Foundations Associates, we acknowledged the need to expand service participation beyond the traditional single-diagnostic care periods early on. Consumers are evaluated individually before moving to less restrictive treatment before Transitional Living. Medication enforcement, attendance at 12-step sessions, and engagement in aftercare services are closely tracked even when consumers are transferred to Dual Diagnoses Improved Halfway House levels of care. Rapid response to relapse or decompensation is provided through comprehensive clinical assessment and supervision, relapse evaluation boards, and adjustments to an individual’s therapeutic contract/treatment plan. Both transitional living and comprehensive clinical assessment are utilized. As one sphere decompensates, the other sphere is monitored in the same way.
• Psychiatric Conditions and Drug Abuse Are Also Manifestations of Chronic, Biological Mental Illnesses that Can Be Described Using a Disease and Rehabilitation Model. Acute stabilization, commitment and motivational reinforcement, successful therapy, and prolonged stabilization, rehabilitation, and recovery are all stages of recovery for each condition. For Transitional Living to be successful, psychoeducation must be a cornerstone of our theory. Getting to know the disease model, coping techniques, drugs, self-monitoring, connectivity of symptoms, and other issues promotes rehabilitation and progress through transitions Transitional Living. Structured community services, house sessions, residential counselling programs, family engagement programs, and the use of a NAMI model called Bridges, which provides consumer-led in-house education groups, are all used to provide psychoeducation. Psychoeducational groups, which emphasize dual rehabilitation, use innovative methodologies to enhance Transitional Living. Furthermore, a sizable portion of the workforce comprises both people in treatment and people who have completed the program. In the same way, society has a big role in fostering Transitional Living changes. Peer Mentors, community-based associations and councils, and a general trend of customer empowerment all play a significant role in promoting rehabilitation.

• There Is No One-Size-Fits-All Solution for Dual Diagnosis. Interventions Must Be Adapted to The Subtype of Dual Condition, the Clinical Diagnosis of Each Disorder, the Stage of Recovery/change, and The Degree of Functional Capacity or Impairment, According to Relevant Practice Guidelines: In this document’s Evaluation section, symptomatology is evaluated, drug history is reviewed, and the applicant’s willingness to adapt to Transitional Living is examined. These dimensions guide the therapeutic approach and clinical treatment by the intervention model. Many of the patients treated at Foundations Associates belong to the 10% of the population that consumes more than 70% of healthcare services at Transitional Living. As a result, the magnitude of the conditions emphasizes the importance of moving through phases of transition at the consumer’s rate. Transitional Living is usually a complex process that begins with recovery phases targeting stabilization, then moves through medium phases focused on adapting to specific lifestyle changes. Finally, late phases focus on cautious, deliberate reintegration. Although the organization promotes abstinence, we understand the population’s psychopathology, the need for several episodes of care, and the value of a successful harm reduction model. Transitional Living is intended to address the desire for change at whatever point the individual is at right now. No penalty is imposed for consumers who are not ready for an abstinence model.
• All of The Individualized Phase-Specific Measures Can Be Used at Any Stage of Treatment in A Managed-Care System. as A Result, a Multidimensional Standard of Care Assessment Is Needed Separately: ASAM measurements are used at the entry to balance treatment/placement needs within the system. Using different assessment protocols, including clinical symptomatology and previous treatment history, transitional living domains are operationalized to guide treatment. Although self-report data has some limitations in data collection, it does allow for a measurement of the consumer’s understanding of the need for care. With this awareness, a client-centered care strategy in Transitional Living is formulated. That perception is the basis for defining a client-driven plan of care that cannot be discounted.

Evaluation

This study Transitional Living, describes how program activities have been changed dramatically throughout this project after input from customers, practitioners, managers, and external consultants. The Foundations conducted an integrated care outcomes study in collaboration with the Tennessee Department of Mental Health and Developmental Disabilities through its Targeted Capacity Expansion grant program, with highly positive results regarding integrated interventions, including Transitional Living.

Baseline Findings Synopsis

Substance Use:

• ASI Alcohol Use Composite Score was slightly lower than ASI normative data (34th percentile)
• ASI Drug Use Composite Score was slightly higher than ASI normative data (75th percentile)
• Predominant drugs-of-choice included alcohol, cocaine (crack), and cannabis
• 70% reported polysubstance abuse of 5 or more years (51% report 10 or more years)

Mental Health Disorders:

• ASI Psychiatric Composite Scores were substantially higher than ASI norms (99th percentile)
• BSI General Psychiatric Severity Ratings were in the 79th percentile relative to psychiatric inpatient normative data.
• 52% had been treated 3 or more times in inpatient psychiatric settings
• 60% reported a serious thought disorder accompanied by hallucinations, such as schizophrenia, schizoaffective, bipolar with psychotic features, etc.
• The average number of DSM-IV Axis I Diagnoses was 2.52.
• The average Global Assessment of Functioning (GAF) score was 46.

Associated Problems:

• ASI Medical Composite Score was slightly higher than ASI normative data (63rd percentile)
• 51% of Foundations’ consumers reported chronic medical problems
• ASI Legal Composite Scores were higher than ASI normative data (80th percentile)
• 51% had been incarcerated for one month or more in their lifetimes
• ASI Family/Social Composite Scores were higher than ASI normative data (79th percentile)
• Rates of homelessness or unstable housing were substantial (37%)
• Rates of abuse were substantial, including emotional (82%), physical (66%), and sexual (45%)

Summary Of Followup Findings

An interview-based longitudinal study conducted by Foundations Associates followed 210 client households permanently in Transitional Living’s residential program for three years. Eighty-eight percent of participants attended at least one follow-up interview. The following are the outcomes:

Substance Use Harm Reduction:

• The number of days drinking any alcohol decreases by 66 percent six months after treatment for customers who indicated the use of alcohol before they entered treatment.
• When users report consuming alcohol to intoxication when they first undergo care, the amount of days they drink alcohol to intoxication decreases by 86% six months later.
• When consumers report using other medications before starting therapy, the number of days they use them decreases by 85% after six months.

Substance Use Abstinence

• The number of days consuming any alcohol decreases by 66 percent six months after treatment for customers who reported the use of alcohol upon entering treatment.
• The number of days drinking alcohol to intoxication declines by 86 percent six months after care for customers reporting use of alcohol to intoxication at the start of treatment.
• After six months, the amount of days spent using other medications decreases by 85% for customers who reported using them before starting care.

Mental Health Disorders & Functional Status

• The BSI findings showed that clinical symptomatology decreased significantly from the 75th percentile at baseline to the 42nd percentile after 6 months.
• The findings of the PAI Schizophrenia subscale showed major reductions in symptoms of thought disorder, primarily confusion, loss of orientation, and attention and concentration difficulties.
• Employment income measures show steady increases over time, rising from $183 per month at the start to $457 per month after six months and $534 per month after a year.

Service Utilization

• Significant decreases in the number of inpatient visits (65 percent reduction in inpatient care for physical problems, 88 percent reduction in inpatient psychiatric treatment, and 91 percent reduction in inpatient substance abuse treatment).
• There has been a significant decline in the use of emergency room facilities (57 percent reduction in emergency room care for physical problems, 92 percent reduction in emergency room psychiatric visits, and 90 percent reduction in emergency room visits related to substance abuse).
• There is no standard method of measuring level progression in the DRA system, and progress is determined by a variety of factors. Transitional Living including psychological health, successful progress through DRA rehabilitation measures, achievement of treatment goals, and various other factors. The onus of change is placed on members to reinforce their obligations to themselves and society. The following are the steps and their related responsibilities:

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