Expanded Capacity of a Transitional Living Facility
Dates of Service: October 1, 1998 through September 30, 2001
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
The intent of the project, funded by SAMHSA’s Center for Substance Abuse Treatment (CSAT), was to evaluate primary and secondary outcomes of a treatment model offering an integrated continuum of care for consumers with co-occurring mental health and substance abuse diagnoses. The project would assess efficacy in primary outcome domains of substance abuse, mental illness, and cost effectiveness, using multiple sources of information to assess each domain. A complete instrumentation package was to be administered 3 times to each evaluation participant to allow detailed estimates of change over time, including the trajectory of change. The project applied multiple sources of information for use in statistical modeling to minimize measurement error and used a longitudinal design for monitoring change. Data collection was to occur at three points for each consumer participating in the project (baseline, six months, and 12 months), with 144 targeted participants expected to participate over the three year period.
Foundations Associates, the project site, was founded in 1995 as an integrated program for providing treatment of co-occurring mental health and substance related disorders. While the key programmatic concepts were already underway at this site, the hybrid nature of the project resulted in barriers in sustaining services within the current treatment system; a system that embraced single state agency, single-diagnosis models of care. At the time of the grant award, the existing Foundations’ program was operational with one 8-bed facility, and there were no public sector funding mechanisms for an integrated residential service model. The project would allow for the agency to develop female services and to expand the continuum of care to more closely align with those defined through the American Society of Addiction Medicine Patient Placement Criteria, Second Version (ASAM-PPC-II).
The project was originally slated to begin September 30, 1998. Delays in budget approvals (i.e., State authority’s inability to authorize project implementation until formal CSAT budget approval) slightly delayed implementation, shifting the start date to January 01, 1999. Additional implementation barriers related largely to securing a “fit” within the existing system, legitimizing the need for dual diagnosis services within both the provider and payer mix and educating the local community about differences in an integrated versus sequential or parallel service model. An example of such a barrier occurred early in the implementation phase, when State licensure requirements stymied the project’s ability to fill available beds. The Division of Mental Health (DMH) initially declined licensure due to the substance dependency component and deferred Foundations’ management to the Bureau of Alcohol and Drugs. The Alcohol and Drug division, while less concerned than the DMH division about the dual status of the population, required commercial zoning for licensure. Because the transitional living facility was residentially based, Foundations was instructed to return to DMH to acquire licensure status. While licensure was ultimately attained through DMH, it occurred approximately one year after efforts were initiated and involved significant education and lobbying. Fortunately, those efforts began prior to the successful award of this project. It is notable that there are still no existing dual diagnosis licensure bodies in the state. A summary of key events occurring during the initial 6 months of implementation follows:
In May 1999, Foundations requested additional funds totaling $49,780 for each of the two remaining contract years, to augment evaluation and programming budgets. Evaluation funds were to be used to hire a part-time interviewer and to pay consumers for participation in follow up evaluations. Programmatic funds were requested to cover various supplies and equipment and a portion of both the clinical director and psychologist’s hours. These funds were approved.
Community awareness of the project was building and, during the third and fourth quarter, admissions maximized. During the third quarter, what would be the highest rate of drop-out occurred due to staff turnover with 10 of the 26 admitted consumers withdrawing from services. With the growth in staff size and the complexity of services, significant emphasis was placed on staff training and defining and standardizing the approach to integrated services. This included intensive training on motivational enhancement techniques, DiClimente’s stage-wise approach to defining readiness to change, psychopharmacologic treatments, and other cross-training topics. The 2nd six month timeframe led to the following additional activities:
Admitted consumers were comprised of 50% male, 19% African American, 73% Caucasian, 8% other, with an average age of 35.7 and an age range of 20-59. Sixty-nine percent reported alcohol use within 30 days of admission (54% to intoxication), 62% reported use of illegal drugs 30 days prior to admission, with other drugs 30 days prior to admission identified as cocaine/crack (46%), marijuana/hashish (35%), and benzodiazapines (19%). Prior housing and living conditions were described as stable during the 30 day period prior to admission by 62% of the consumer population, while 27% were institutionalized during that timeframe and 12% were formerly residing in shelters. Substance use/abuse was noted as extremely stressful by 81%, while 65% reported substance use forced forfeiture of important activities.
Operational Phase – Year Two
By year two, the program was fully operational and consumers were being waitlisted as the volume of referrals continued to grow. The need to emphasize energies on two key areas was emerging:
- In order to ensure services remained fully “integrated,” cross training of professional and non-professional staff required ongoing emphasis.
- While the community was accepting of a grant program to treat what was considered a “difficult to treat” population, community insights regarding integrated care, dual diagnosis, or the value of funding, had not yet begun to surface.
With regard to the former, TCE funding permitted staffing expansion to include multi-disciplinary clinical staff such as psychiatrists, psychologists, clinical social workers, and alcohol and drug abuse counselors; however, philosophical perspectives of treatment among clinicians varied extensively. Philosophical training perspectives and biases in treatment approaches had to be addressed in a manner that extracted strengths-based and client-centered elements from both realms of treatment. Cross-training of mental health professionals consisted of education in 12-step philosophies, disease concepts, relapse prevention, and abstinence. Traditional alcohol and drug professionals required education emphasizing psychotropic medications and their purposes and side effects, empathic understanding and listening skills, and harm reduction theories. All staff members were and continue to be educated on motivational enhancement techniques. It was immediately clear that, before different disciplines can address dual treatment, identification of differing philosophical perspectives and ongoing training, education, and experience were requisite to developing competencies.
At the same time, while evolving literature clearly supported the construct of integration practices, available literature was construct- and theory-based and failed to offer specific operational integration techniques. Therefore, effort were directed at developing and defining operational practices that could be replicated as integrated approaches to treatment as part of the CSAT model program. One of the key insights discerned through this project was the realization that philosophical tenets typical of traditional service programs can be greatly incongruent with the mission of an integrated program. Agency efforts, therefore, must continuously strive to develop a new culture that reinforces the strengths of multiple disciplines and encourages “out of the box” treatment paradigms. Non-confrontational, motivational treatment using harm reduction, methods for theory integration, aspects of psychopharmacology, and Dual Recovery Anonymous were addressed weekly in staff training.
Regarding the latter issue of sustainability, it was immediately clear that consciousness-raising efforts were critical to engaging community support for integrated services. While private sector funding sources have increasingly been amenable to creative solutions and respond to long-range efficacy data, public sector systems are typically slower in their acceptance of modified delivery systems. Ongoing community education and marketing endeavors were targeted at broadening community awareness of the impact of co-morbidity and the importance of defining funding streams amenable to supporting integrated treatment. Foundations Associates, through its Dual Diagnosis Recovery Network, launched a media campaign consisting of statewide and local conferences, publication of a newsletter on co-occurrence, and development of an anti-stigma media packet. By the conclusion of year two, several private contracts had been secured, however, State Medicaid officials had not expressed willingness to provide reimbursement for integrated residential treatment. Sustainability was the most impenetrable challenge and, despite federal funding through the Substance Abuse Mental Health Service Administration (SAMHSA) for treating dual disorders, grant funding streams for individual states remained separate and divided. Although Tennessee’s substance abuse and mental health block grant dollars were blended through a Medicaid waiver, the state continued to struggle with methods for blending funds for mental health and substance abuse services.
Key activities occurring during the second year of operations were as follows:
Of the population served during year two, alcohol, cocaine/crack, and marijuana were the most frequent substances used. Predominant diagnoses consisted of bipolar disorder with psychotic features, and major depression with psychotic features. More than of admitted consumers were also diagnosed with a personality disorder. The ethnicity of the consumer base was consistent with the ethnic breakdown in Nashville. Consumers reported a higher proportion of medical problems than clients in normative substance abuse programs, with employment problems comparable to other public facilities though substantially in excess of most private facilities. In addition, consumers reported comparatively more legal problems than clients from average treatment programs and more family and social programs. Consumer profiles reflected substantially more psychiatric impairment than with typical substance abuse treatment programs.
Operational Phase – Year Three
The third year of services focused on and aggressively addressing sustainability. It was clear that community education activities were resulting in increasing recognition of the complexities of dual diagnosis on both the local and national levels. Preliminary outcome data was suggestive of strong positive long range outcomes for program participants, and both local and national attention was increasingly focused both on co-occurrence as an important societal issue and Foundations as a promising model of treatment. As such, public sector payers were more responsive to entertaining discussions related to funding and , one month before the conclusion of the TCE grant, a variety of services were funded to Foundations Associates to permit sustainable and expanded programming. These are described below, along with other key tasks that occurred during that period.
With the limitations in available literature regarding methodologies for integrating treating, significant effort was expended throughout the project to operationalize those strategies. In the following subsections, we identify assessment, treatment, and staffing elements we believe to be essential to successful treatment integration.
One key aspect of Foundations’ assessment model is that primary assessment responsibility lies in the hands of a single clinician, as opposed to alternative models that distribute intake assessment responsibility across several staff. The consolidated approach serves to maintain a high level of consistency across assessments and ensures that intake assessments are conducted by a clinician experienced assessing both the severity of substance use and the extent and nature of co-morbid mental health conditions. The intake responsibility was centralized to one admissions counselor who would administer all core assessment materials used for clinical evaluation (and research), generate summary report requirements, and make appropriate referrals for other needed clinical assessments (e.g., psychiatrist, psychologist, or other specialists).
At program implementation, newly emerging integrated assessment protocols had not yet established reliability and validity for this population. As such, a group of assessments were selected with established reliability and validity in populations similar to that served by Foundations Associates, i.e., predominantly individuals with substance dependency conditions and serious mood or thought disorders. The complete protocol included elements of both clinician-report and self-report, in order to minimize the impact of biases on the part of the clinician or the consumer. Accommodations were made as needed to the basic assessment package, depending on the presenting needs of the consumer and with particular sensitivity to diagnostic severity, reading level, special needs or disabilities, and cultural considerations.Non-standardized protocols were developed to achieve two ends:
- Operationalize ASAM PPC-IIR measures to facilitate decision-making regarding placement. This included application of the ASAM crosswalk and development of specific criteria that defined medical necessity standards for each level of the Foundations’ continuum of care, and;
- Provide depth to the psychiatric portion of the evaluation to offer a platform for integrating treatment elements. This included an in depth interview regarding the consumer’s family of origin, behavioral health and substance dependency treatment history, prior traumas, behavioral trends, psychiatric symptomatology, and psychopharmacologic treatment history.
Assessment components included:
1) Prescreening (completed by referring agency or administrative staff)
- Brief Referral Form with succinct diagnostic and treatment history
- Consumer completes Stages Of Change Readiness and Treatment Eagerness Scale (SOCRATES; Miller & Tonigan, 1996)
2) Intake Assessment
- Comprehensive Psychosocial Interview: treatment history; multiaxial DSM-IV diagnostic assessment; mental status examination; assessment of contributing factors, including: social/family/peer concerns, legal, cultural, spiritual, vocational, housing, abuse, and other consumer-specific issues; information from collateral informants; Release of Information; eligibility for public assistance).
- Standardize assessment battery: Addiction Severity Index (ASI), Brief Symptom Inventory (BSI), Personality Assessment Inventory (PAI) (Schizophrenia Subscale), Quality of Life Inventory (Customized Lehman’s QOLI), Empowerment Survey.
- American Society of Addiction Medicine (ASAM) PPC-IIR Multidimensional Assessment
- Initial Treatment Planning Recommendations
3) 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
4) Psychologist or other Specialized Assessment (as needed)
- Objective or Projective Psychological Testing
- Laboratory Tests (Serum or Urine Toxicology)
- Vocational Assessment
- Nursing Assessment
- Case Management Assessment; need for collaborative services
- Referrals for additional assessment as needed
The assessment process was used to determine the consumer’s appropriateness for Foundations’ integrated residential program, key clinical problems, and individualized treatment strategies. If a consumer was deemed a poor match for Foundations’ residential program (due to a single diagnosis, poor fit with individual treatment needs, or recommendation for another level of care), the appropriate referral was expedited.
Staff training emphasized that assessment is frequently the first opportunity for an agency to effectively engage the consumer and begin a positive therapeutic relationship. Intake assessment personnel were encouraged to build immediate positive rapport with the consumer and, as a representative of the program, work toward an empathetic bond of trust and empathy. This is particularly important for programs serving consumers with co-occurring disorders, frequently veterans of treatment, as it reflects program sensitivity to consumer needs (and motivational status) and plants a seed of hope regarding future treatment efforts.
The intake assessment is only the first step in an ongoing assessment process, in which clinicians continually collect information about the consumer in order to tailor treatment more effectively to individual needs. It is understandably difficult to elicit a comprehensive diagnostic description and problem summary during a brief intake assessment session in which initial rapport must also be established. Ongoing assessment is particularly important for programs addressing co-occurring disorders, due to the inherent challenge of differential diagnosis of substance-induced versus mental health disorders. It is well known that commonly associated sequelae of substance use disorders (e.g., hallucinations, delusion, paranoia, etc.) can mimic symptoms of mental health disorders and vice versa. Given a common set of presenting symptomatology, a clinician can only make differential diagnoses based upon historical information regarding usage patterns and associated symptoms and after a period of abstinence from illicit substances. This is particularly important if the consumer presenting for treatment services has not had a recent period of significant abstinence. In his case, program staff must carefully monitor changes in clinical status after program entry, to effectively distinguish effects of substance use versus mental health symptomatology. Therefore, emphasis was placed on collection of clinical information as part of the ongoing assessment process to be incorporated into individualized treatment plans, update treatment objectives, evaluate progress toward objectives, and continually assessing step-down and discharge goals.
Individual therapy and case management plans were established at admission to evaluate the life domains of mental health, physical health, vocational/educational, financial, housing/life skills, spiritual, and recreational/social. Each individual was assigned a primary therapist to coordinate care planning. Service matching was determined through the assessment, and the individual was directed either to outpatient or residential services. Service elements are described below.
Admissions to crisis stabilization typically result in a 72-hour stay to stabilize psychiatric or substance abuse symptoms and/or medication adjustments for individual at acute risk for inpatient psychiatric care. The goal of this program is to provide interim crisis services until the individual is stabilized and the level of services can be reduced through structured residential and aggressive pharmacologic treatments. Once stabilization occurs, the consumer may be linked to community services or placement or, as appropriate, may be enrolled in Foundations’ continuum of services. Crisis services include 24-hour staff supervision, regular monitoring by a psychiatric nurse specialist, and ongoing psychiatrist evaluations with on-call 24-hour response by medical and clinical staff. Although not initially intended solely to serve dually diagnosed consumers, in excess of 60% of consumers served through diversionary services are dually diagnosed. This program provides a natural trajectory in identifying high-risk populations with concurrent disorders and enrolling them in non-traditional integrated services. All remaining Foundations programs serve only dually diagnosed consumers, with the majority diagnosed with Axis I mood or thought disorders with comorbid substance dependency.
Dual Diagnosis Enhanced Therapeutic Community (DDETC)
The DDETC component is provided through eight-bed residentially based houses licensed by the Tennessee Department of Mental Health and Developmental Disabilities. Key program components include:
- Length of stay: Length of stay in the DDETC averages six weeks to three months depending upon level of symptomatology, usage history, and progress in treatment. As appropriate, again determined diagnostically and by individual presenting circumstances, the consumer may move through the Foundations’ housing continuum or into community-based treatment following completion of this phase of services. An earned system of privileges combines completion of treatment goals with effective step work and milieu accomplishments to define when and how progression occurs.
- Staffing: Staffing consists of 24-hour wake staff supervision by resident counselors, a majority of which are mentors in recovery and program graduates. In addition, a master level therapist is stationed onsite during business hours and a family therapist/educator is on-site each Sunday during visitation. The weekday therapist works closely with the consumer and his/her family through individual sessions, family therapy, and development of collaborative targeted goals for recovery. The weekend therapist conducts a monthly education program for the consumer’s support group to address the dynamics of dual recovery, the importance of medication, and develop individualized reintegration plans that enhance and emphasize both natural and formal supports. Families and support systems are encouraged to participate in NAMI support groups. Twenty-four hour crisis call availability occurs through both the Foundations Associates’ clinical staff and the regional mobile crisis response team. Through the group therapy/psychoeducation component, all consumers are evaluated and treated by a licensed psychiatrist for psychopharmacologic interventions. Non-confrontational, motivational interviewing techniques are required by all staff and are emphasized in orientation, trainings, and as a key focus of weekly clinical meetings.
- Psychoeducation/Therapy: The psychoeducation/therapy program provides a five days per week, three hours per day intensive, integrated dual treatment program with three daily groups, each one hour in length, designed to provide psycho-education, addictions treatment, relapse prevention, therapy, and coping strategies. The foremost premise of psychoeducation/therapy is that all modules are structured to address the confluence of both disorders in a manner that educates and instills hope in recovery. The second premise, which is considered equally important in an integrated regimen, is the application of DiClimente’s stage-wise approach for defining treatment according to the individual’s readiness to change. Cognitive therapy and motivational interviewing are integrated with a twelve-step dual recovery intervention, where staff training focuses upon non-confrontational methods of directing change. Psychiatric evaluation, medication management, individual psychotherapy, and case management are also provided for all participants by a treatment team comprised of psychiatrists, psychologists, clinical social workers, and certified alcohol and drug counselors.
- Peer Mentors: At admission all consumers are assigned a peer mentor. Peer mentors have successfully accomplished key personal recovery goals and are nearing the conclusion of the initial phase of treatment. The role of the mentor is to assist in orientation, acclimation, and to offer a hope-in-recovery perspective.
- Community milieu elements: Shared responsibilities for the community is an expectation from the date of entry and throughout participation in the program. Residents conduct cooking, cleaning, and other routine chores with staff participation through modeling and teaching. The extent of staff assistance is based upon consumer need and staff members are expected to participate as a member when less educational assistance is needed. Peer mentors also act as primary teachers.
- Peer Review Committee (PRC): While the model reinforces abstinence, the profile of the served population and the recognition of stages in recovery lends to an acknowledgement and acceptance that harm reduction elements must be incorporated. When relapse occurs for an active program enrollee and s/he desires to continue treatment, the consumer must complete a Relapse Self Evaluation. The Relapse Self Evaluation is a protocol that encourages introspective analyses of triggers, relapse planning, and an assessment of impact of the relapse on the individual, community, and support systems. The member presents his/her evaluation to the larger community and is rated by committee members according to both prior motivational and engagement characteristics and proposed relapse planning. The committee’s role is to determine whether the individual can remain in treatment or will otherwise be transferred to more traditional treatment resources. This process has had considerable impact on both the consumer and larger community in evoking change and empowering community responsibility for individual members. A copy of the protocol, that includes elements identified by the treatment community to be included in this process, follows.
- Integrated schedule elements: The residential model includes a combination of recovery and treatment therapies to provide diagnostic education, medication education and management, develop relapse plans, and encourage participation in 12-step models of intervention, particularly Dual Recovery Anonymous (DRA). All treatments address the interrelatedness of co-morbidity and, as with the outpatient model, a combination of psycho-educational modules occurs in conjunction with didactic therapies. Medication education groups and medication supervision is an inherent part of the community program. The program schedule includes:
- Progressive levels of privilege: The decision for movement through the level system is contingent upon psychiatric stability, effective movement through the DRA recovery steps, attainment of treatment goals, and various responsibility factors. The onus of progress occurs through reinforcement of member responsibilities both to themselves and the community at large. Steps and their attendant responsibilities occur as follows:
Entry level is an orientation phase for transitional living, offering the consumer an opportunity to become comfortable with the staff, residents and structure of transitional living. Consumers’ requests for visits with family, initial case management needs, and doctor’s appointments are scheduled through the primary therapist.
Level 1: Intensive Residential Phase
Individual weekly therapy remains a part of the Level 1 phase of treatment. Level 1 residents may begin to take part in weekly outings and off-campus support group meetings. If the clinical treatment team (including the Housing Coordinators, Clinical Director, Psychiatrist, and Psychologist) has determined through case review that the consumer has successfully completed Entry Level requirements, the consumer may proceed to Level 1. This phase is the beginning of the consumer’s transition back to independent living.
Level Two: Intermediate Residential Phase
During this phase, Foundations’ staff assists the consumer in strengthening independent living skills and accepting greater responsibility for personal recovery.
Level Three: Transitional Phase
Elevation to this phase indicates that the clinical treatment team feels the consumer has successfully completed Foundations’ Intensive Outpatient Program.
Level Four: Community Reintegration Phase
Promotion to Level Four reflects that the consumer is working the 12-Step recovery program on a daily basis, as determined by the clinical treatment team and the consumer, and consistently demonstrates honesty and a sense of responsibility toward themselves and others.
Level Five: Independent Living
Attainment of Level Five status means the individual has demonstrated commitment to recovery and personal growth. Level Five reflects that the individual has consistently been responsible for all aspects of his/her recovery, is working the 12-Step recovery program on a daily basis, and demonstrates honesty and a sense of responsibility toward themselves and others.
Movement through the program is consistently reevaluated through consumer peer review committees, house meetings, and through individual therapeutic contacts. Level regression may occur as a result of increased psychiatric symptoms, relapse, during increased environmental stressors, or due to rule violations. Depending upon the circumstances, both the community and the treatment team actively participate in most decisions regarding level changes.
Following the initial intensive six-eight week phase of care, a decision regarding whether the individual remains in the Foundations’ continuum is based upon both service availability and medical need. Consumers with repeat inpatient psychiatric and substance abuse treatment histories, an inability to maintain extended sobriety without supports, and presenting with high-risk environments are typically deemed medically appropriate for continued care. When services are unavailable or inappropriate, the teams focus is to enhance natural and formal support systems and aggressively work toward reintegration planning during the final two weeks of participation in the intensive phase of treatment. Participation in Foundations’ Aftercare program is a requirement for all consumers who remain in Foundations’ housing following intensive treatment. Aftercare services are strongly encouraged for all other program graduates and include big-book study, recreational activities, and a focus on reintegration issues that typically affect the dually diagnosed individual.
Dual Diagnosis Enhanced Halfway House (DDEHH)
If DDEHH services are appropriate and available, the resident is offered step-down (ASAM PPC-IIR Level III.3 half-way houses) bundled with a range of nonresidential services including individual, group, and family therapy. DDEHH services average 2-4 months and are provided in 5-bed houses licensed by the Department of Mental Health and Developmental Disabilities and located within blocks of DDETC housing. As opposed to the 24-hour staffing plan in the intensive program, clinical staff are available 8-hours per day with twenty-four hour crisis call availability through both the Foundations Associates clinical staff and the regional mobile crisis response team. Consumers check-in with intensive residential program staff when arriving and leaving the premises for approved passes. A master level Independent Living Housing Coordinator works closely with each consumer in this level of care to develop and address goals and reintegration planning, with life skills, personal responsibility, independence, and structure, as the primary focus of treatment. A vocational specialist works with all consumers to address the spectrum of vocational educational needs from developing resumes and establishing a job search plan to directly teaching skills through a supportive employment plan. All residents participate in development of an individualized Therapeutic Contract that defines community, individual, and financial/rental goals and arrangements. There is no treatment charge for this level of care, and consumers are required to be competitively employed and pay market rate rent. Food and utilities are included under this arrangement.
Dual Diagnosis Enhanced Independent Living (DDEIL)
Supervised independent living is the final phase of the Foundations continuum. Foundations support services are determined via an individualized therapeutic contract that identifies community, individual, vocational and financial goals/agreements. Therapy sessions are reduced to monthly or bimonthly contacts, and the consumer is responsible for coordinating community services, psychiatric visits, medications, and other needs. Aftercare participation remains a standard requirement. Length of stay in DDEIL housing ranges from 2-4 months. As with the halfway house, consumers are required to be competitively employed and pay market rate rent. Food and utilities are included under this arrangement.
Principles and Course of Treatment
Foundations Associates’ residential program attained model project status for integrated treatment by SAMHSA as one of three exemplary programs in the United States featured at the Co-occurring Institute of the SSDP V (State System Development Program 5th) Conference, and the residential services were also recently selected as a finalist for the American Psychiatric Associations’ (APA) Gold Achievement Award. The residential program offers a comprehensive treatment plan covering a continuum of case management, psychopharmacologic treatment, vocational rehabilitation, psychoeducation, individual and group therapy, and 12-step treatments and interventions. The program premise is based upon key elements best described by Minkoff as the seven principles inherent in an integrated model of care:
1. Comorbidity is an expectation, not an exception
Based upon the 4-quadrant subtyping of disorders, Foundations Associates has historically served the high severity SPMI/substance dependency population, with the majority of consumers having experienced multiple psychiatric and substance dependency treatment episodes prior to admission. Pacing treatment according to individual needs was early identified as an essential component and, despite frequently needing to stabilize presenting issues such as post withdrawal or subacute symptomatology, program elements repeatedly include educational components that address the confluence of disorders. Individual educational and treatment elements are of short duration, frequently repeat topics, and reinforce treatment of the consumer at his/her level of cognitive understanding.
A continuum of services was designed to address integrated care across all service levels, including case management, therapeutic interventions, 12-step approaches (i.e., application of a dual recovery model), and psychopharmacologic treatment. While the goal was to recruit staff trained in integrated theories, where possible, integrated skills were early discovered to be rare commodity. Hence, staff training, workshops, conferences, educational forums and the like are encouraged for all staff to broaden experience in dual treatment. Likewise, staff members rotate presentations in weekly meetings on contemporary treatment approaches to integrated care. As part of the Dual Diagnosis Recovery Network (DDRN), a library that serves as a national repository of dual diagnosis research, information is available onsite to all staff.
2. Successful treatment requires most importantly the creation of welcoming, empathetic, hopeful, continuous treatment relationships, in which integrated treatment and coordination of care are sustained through multiple treatment episodes.
All program elements are directed toward emphasizing staff/client relationships in an engaging, non-punitive atmosphere. From the initial assessment information, a plan of care is established that views both disorders as co-primary, addresses dual recovery, and is based upon the individuals readiness to change. Staff is directed not to impose traditional treatment goals, rather to establish client driven plans of care. Relapses and decompensations are viewed as characteristic of the pathology of the conditions and efforts are aggressively directed to re-engaging the client when those events occur. These episodes are used to enhance consumer introspection regarding triggers and symptoms of relapse and decompensation and are addressed through community meetings and individual therapy sessions.
Rather than relying on traditional approaches, efforts are made to develop resources that meet the needs of the dually diagnosed consumers. For example, housing is an always-difficult service to obtain for the complex dually diagnosed consumer. Absent sufficient resources to place consumers following treatment in the continuum, Foundations empowered consumer groups and provided financial assistance to develop cooperative housing based upon Oxford residential models. In addition, collaborative relationships were established with several community-based programs to earmark housing services specifically for Foundations populations.
3. Within the context of the continuous integrated treatment relationship, case management and caretaking must be balanced with empathetic detachment and confrontation in accordance with the individuals level of functioning, disability and capacity for treatment adherence.
The balance between traditional normative mental health caretaking versus substance abuse empathetic detachment is attained through individual plans of care that are developed through the course of a aggressive treatment planning. Ongoing modification to plans of care occurs through weekly team evaluation of the individuals progress in treatment. Typically efforts during the earlier phases of treatment are directed toward stabilizing psychiatric symptomatology and managing withdrawal symptoms and associated cravings. Hence, typically the first two weeks result in a higher level of staff case management and caretaking efforts. As stability progresses the onus gradually shifts to responsibilities the consumer bears in directing the course of treatment. Level systems, based upon symptom and withdrawal management and progress in the program, direct the changes to the structure of the relationship. Level systems offer an earned system of privileges that combine completion of treatment goals with effective step work and milieu accomplishments to define when and how progression occurs. Successful progression is determined in house meetings by both the consumer population and therapy staff.
4. When mental illness and substance disorder co-exist, both disorders should be considered primary, and integrated dual primary treatment is required.
Aggressive psychopharmacologic treatment and monitoring, applied in conjunction with recovery principles such as sober, structured housing and DRA are essential to a co-primary treatment approach. Given the severity of the population treated at Foundations Associates, we early identified the need to extend the length of program participation outside of normative single-diagnostic treatment periods. Instead, consumers are evaluated individually according to progress in the program, level of stability attained, and related characteristics before movement to less restrictive care occurs. Even when consumers are moved to Dual Diagnoses Enhanced Halfway House levels of care, medications continue to be monitored closely, as is attendance at 12-step meetings and participation in aftercare programs. In the event of relapse or decompensation, interventions are rapidly rallied either through intensive psychiatric evaluation and monitoring, relapse evaluation committees and modifications to the individual’s therapeutic contract/treatment plan, or a combination of both. When decompensation in one sphere occurs, attendant monitoring of the other sphere is accordingly engaged.
5. Both psychiatric illnesses and substance dependence are examples of chronic, biological mental illness which can be understood using a disease and recovery model. Each disorder is characterized by parallel phases of recovery: acute stabilization, engagement and motivational enhancement, active treatment, and prolonged stabilization, rehabilitation and recovery.
Psychoeducation is a hallmark of this principle, in that education on the disease model, management strategies, medications, self-monitoring, inter-relatedness of conditions, and the like bring to bear the element of hope in recovery and facilitate movement through stages of change. Psychoeducation occurs through structured group programs, house meetings, residential therapy programs, family education programs, and use of a NAMI model, Bridges, which offers consumer led in-house education groups. All psychoeducational groups integrate dual recovery as a central theme, emphasizing methodologies for maximizing quality of life. In addition, a significant majority of staff includes both individuals in recovery and graduated program consumers.
Similarly, the impact of the community as a whole is significant in facilitating change. Peer Mentors, community driven groups and committees, and a general theme of consumer empowerment immeasurably emphasize recovery elements.
6. There is no single correct dual diagnosis intervention. Appropriate practice guidelines require that interventions must be individualized, according to the subtype of dual disorder, specific diagnosis of each disorder, phase of recovery/stage of change, and level of functional capability or disability.
The protocols discussed at the Assessment section of this document are used to define level and extent of symptomatology, history of substance use, and readiness to change. These dimensions direct the approach to treatment and clinical treatment matching with the model of intervention. Again, the population treated at Foundations Associates predominantly consists of the 10% of the population using in excess of 70% of the healthcare resources. As such, the severity of the conditions reinforce that movement through stages of change must occur at a pace directed by the consumer. Typically early phases of treatment are directed at stability, medium phases at defining personal goals and plans for attaining those goals, and later phases toward careful, deliberate reintegration.
While the agency espouses an abstinence orientation, we recognize the psychopathology of the population, the typical multiple episodes of treatment, and the importance of an effective harm reduction model. Consumers not ready for an abstinence model are treated non-punitively and efforts remain directed at addressing the individuals motivation for change at whatever stage s/he is currently prepared.
7. Within a managed-care system, any of the individualized phase-specific interventions can be applied at any level of care. Consequently, a separate multidimensional level of care assessment is required.
ASAM dimensions are applied at admission to attempt to match treatment/placement needs within the system. Domains are operationalized to direct the plan of care by incorporating various protocols that measure psychiatric symptomatology, treatment history, and a combination of other psychiatric and substance dependency measures. While reliance on self-report information contains certain faults in data gathering, it permits a measure of the consumer’s perception of need for treatment. That perception is the basis for defining a client driven plan of care that cannot be discounted.
As described throughout this report, program practices have evolved considerably throughout the course of this project based on feedback from consumers, clinicians, administration, and external consultants. Through the Targeted Capacity Expansion grant program, Foundations implemented a longitudinal evaluation of integrated treatment outcomes in collaboration with the Tennessee Department of Mental Health and Developmental Disabilities with highly promising results regarding outcomes related to integrated intervention modalities.
Summary Of Baseline Findings
- 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.
- 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
Foundations Associates completed a 3-year longitudinal research investigation, conducting intake interviews on 210 consumers entering Foundations’ residential program with at least one followup interview completed on 88% of study participants. Results follow:
Substance Use Harm Reduction:
- For consumers reporting any use of alcohol upon entry to treatment, the number of days drinking any alcohol drops by 66% six months after treatment.
- For consumers reporting use of alcohol to intoxication upon entry to treatment, the number of days drinking alcohol to intoxication drops by 86% six months after treatment.
- For consumers reporting use of other drugs upon entry to treatment, the number of days using other drugs drops by 85% after six months.
Substance Use Abstinence
- For consumers reporting any use of alcohol at baseline, 60% report abstinence from any alcohol use after six months.
- For consumers reporting use of alcohol to intoxication at baseline, 67% report abstinence from using alcohol to intoxication use after six months.
- For consumers reporting use of other drugs upon entry to treatment, 82% report abstinence from other drug use after six months.
Mental Health Disorders & Functional Status:
- BSI results showed a significant reduction in psychiatric symptomatology from the 75th percentile at baseline to the 42nd percentile after 6 months.
- The PAI Schizophrenia subscale results documented substantial reductions in symptoms of thought disorder, specifically confusion, lack of orientation, and difficulties with attention and concentration.
- Measures of employment income show steady increases over time, from $183/month at baseline to $457/month after six months and $534/month after one year.
- Substantial reductions in inpatient visits (65% reduction in inpatient care for physical problems, 88% reduction in inpatient psychiatric treatment, and 91% reduction in inpatient substance abuse treatment).
- Substantial reduction in utilization of emergency room services (57% reduction in emergency room care for physical problems, 92% reduction in emergency room psychiatric visits, and 90% reduction in emergency room visits related to substance abuse)
- Increase in appropriate utilization of less restrictive, community-based outpatient services (178% increase in outpatient visits for physical problems, 94% increase in outpatient psychiatric visits, and 5% reduction in agency-based outpatient visits related to substance abuse, accompanied by a 108% increase in use of self-help.)