A Transitional Living Facility with a Larger Capacity

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Last Updated on March 27, 2021 by

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

The project’s aim, which was sponsored by SAMHSA’s Center for Substance Abuse Treatment (CSAT), was to assess the primary and secondary effects of a treatment model 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. Each evaluation participant was to receive a full instrumentation package three times in order to obtain detailed estimates of change over time, including the trajectory of change. To reduce measurement error, the project used multiple sources of data in statistical modeling and used a longitudinal design to track progress. Data was to be collected at three points for each user involved in the project (baseline, six months, and twelve months), with 144 people targeted to take part over the three-year cycle.

Background/Implementation of the Project

The project site, Foundations Associates, was formed in 1995 as an integrated network for the treatment of co-occurring mental health and drug use disorders. 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 time of the grant award, and there were no public sector funding mechanisms for an integrated residential service model. 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, and educating the local community about the discrepancies between an integrated versus sequential or parallel service model. State licensure provisions stymied the project’s ability to fill available beds early in the implementation process, for example. 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:


Foundations sought an additional $49,780 in funding for each of the two remaining contract years in May 1999, to supplement assessment and programming budgets. Funds from the assessment were to be used to employ a part-time interviewer and to 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, as well as other supplies and equipment. The funds have been authorised. The project was gaining traction in the community, and admissions soared in the third and fourth quarters. Due to staff turnover in the third quarter, the highest rate of drop-out occurred, with 10 of the 26 accepted customers withdrawing from programs. Staff preparation and identifying and standardizing the approach to integrated services were given a lot of attention as the staff size and complexity of services grew. Intensive instruction in motivational enhancing strategies, DiClimente’s stage-wise approach to defining readiness to adapt, psychopharmacologic therapies, and other cross-training issues were among the topics covered. The following activities were introduced during the second six-month period:


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.


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 allowed for the addition of multi-disciplinary health personnel such as physicians, psychologists, clinical social workers, and alcohol and substance addiction counselors to the former; however, clinicians’ ethical views on care differed greatly. Philosophical preparation perspectives and treatment biases had to be approached in such a way that strengths-based and client-centered components were derived from all domains of treatment. Mental health workers were given lessons in 12-step philosophies, disease principles, relapse prevention, and abstinence as part of their cross-training. Traditional alcohol and drug practitioners required training in psychotropic drugs, their uses and side effects, empathic comprehension and listening skills, and harm reduction theories, among other things. Motivational enhancement methods were taught to all employees, and they are still being taught. It was clear right away that identifying varying philosophical viewpoints as well as ongoing preparation, education, and expertise were required before various disciplines could discuss dual treatment.

Simultaneously, while emerging literature strongly endorsed the construct of integration activities, existing literature was construct- and theory-based and lacked concrete operational integration techniques. As a result, as part of the CSAT model program, efforts were focused on creating and identifying operational practices that could be replicated as comprehensive treatment approaches. The recognition that philosophical tenets characteristic of conventional service systems can be greatly incongruent with the mission of an integrated program was one of the core insights gained through this project. As a result, organization efforts must continue to aspire to establish a modern culture that draws on the strengths of various disciplines while promoting “out of the box” care paradigms. Weekly staff training included non-confrontational, motivational therapy with damage reduction, approaches for theory integration, facets of psychopharmacology, and Dual Recovery Anonymous.

In terms of the above topic of sustainability, it was clear right away that community awareness-raising activities were essential for gaining community support for integrated services. 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. Ongoing community outreach and marketing efforts aimed to raise community awareness of the effects of comorbidity and the value of identifying funding sources that could promote integrated care. Via its Dual Diagnosis Recovery Network, Foundations Associates initiated a media initiative that included statewide and local conferences, the publishing of a newsletter on co-occurrence, and the development of an anti-stigma media packet. 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. The most insurmountable obstacle was sustainability, and 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. Despite the fact that Tennessee’s drug abuse and mental health block grant funds were merged by a Medicaid waiver, the state’s strategies for blending funds for mental health and substance abuse programs remained a problem.

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


Alcohol, cocaine/crack, and marijuana were the most commonly used drugs by those served in year two. Bipolar disorder with psychotic features and major depression with psychotic features were the most common diagnoses. A personality disorder was diagnosed in more than half of the admitted customers. The ethnic makeup of the customer base matched Nashville’s ethnic breakdown. Consumers registered a higher proportion of medical issues than clients in typical substance abuse services, as well as job issues that were equivalent to those in most public facilities but far exceeded those in most private facilities. Furthermore, customers identified more legal issues than clients in typical recovery services, as well as more family and social programs. In comparison to traditional substance abuse recovery services, consumer profiles revealed significantly more psychological illness.


The third year of programs was dedicated to approaching sustainability in a proactive manner. On both the local and national levels, it was evident that community outreach programs were resulting in increased understanding of the nuances of dual diagnosis. Preliminary outcome research suggested that program participants would have strong positive long-term results, and both local and national attention was increasingly focusing 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, and one month before the TCE grant ended, Foundations Associates earned funding for a range of programs to allow sustainable and expanded programming. These, as well as other essential tasks performed during that period, are detailed below.


Program Description

Since there was a lack of available literature on methodologies for incorporating treatment, a lot of work was put into operationalizing certain methods during the project. We define evaluation, care, and staffing components that we believe are critical to effective treatment integration in the paragraphs that follow.


One of the most important aspects of Foundations’ assessment model is that primary assessment responsibility is vested in a single clinician, as opposed to other models that delegate intake assessment responsibility among many workers. The consolidated strategy ensures that evaluations are performed by a clinician who is competent in determining both the seriousness of drug use and the magnitude and type of co-morbid mental health conditions. One admissions advisor was in charge of the intake process, which included administering all core assessment materials used in clinical evaluation (and research), generating summary report criteria, and making necessary referrals for additional clinical evaluations (e.g., psychiatrist, psychologist, or other specialists).

Newly developed integrated evaluation protocols had not yet defined reliability and validity for this population at the time of program implementation. As a result, a group of tests with proven reliability and validity in communities similar to those served by Foundations Associates, i.e., mostly people with substance abuse issues and severe mood or thinking disorders, were chosen. To mitigate the effect of biases on the part of the clinician or the patient, the entire procedure included elements of both clinician-report and self-report. Accommodations to the basic evaluation kit were rendered as required, based on the consumer’s presenting needs and with specific attention to medical intensity, 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:

1) 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)

2) 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

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

Assessment is often the first opportunity for an organization to successfully engage the consumer and begin a constructive therapeutic partnership, according to staff training. Intake assessment staff were encouraged to establish an immediate positive rapport with the client and work for an empathetic bond of confidence and empathy as a representative of the program. 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.

The intake assessment is just the beginning of a continuous assessment process in which clinicians gather knowledge about the consumer in order to better adapt care 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. Due to the inherent complexity in differentiating between substance-induced and mental health conditions, continuous assessment is especially relevant for services treating co-occurring disorders. It is well known that common drug use disorder sequelae (e.g., hallucinations, delusions, paranoia, and so on) can resemble symptoms of mental health disorders and vice versa. A clinician may only make differential diagnosis based on historical knowledge about consumption trends and related symptoms, as well as after a time of abstinence from illegal drugs, provided a standard collection of presenting symptomatology. This is especially crucial if the person seeking care hasn’t had a substantial time of abstinence recently. 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. As a result, the gathering of clinical evidence as part of the ongoing evaluation process was stressed, with the goal of integrating it into individualized care plans, reviewing treatment objectives, monitoring progress against targets, and constantly assessing step-down and discharge goals.

Program Elements

At the time of admission, individual counseling and case management plans were created to assess mental health, physical health, vocational/educational, financial, housing/life skills, spiritual, and recreational/social spheres of life. A primary therapist was assigned to each person to help with care coordination. The assessment decided whether the person would benefit from outpatient or residential treatment, and the individual was directed accordingly. 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/or prescription changes. This program’s aim is to provide interim trauma care until the person is stable and the level of services can be decreased through standardized residential and aggressive pharmacologic treatments. After stabilization, the consumer can be connected to community services or placement, or enrolled in Foundations’ continuum of services, as necessary. 24-hour staff oversight, daily monitoring by a psychiatric nurse practitioner, and ongoing psychiatrist assessments and on-call 24-hour medical and clinical staff are also provided in crisis care. Despite the fact that diversionary programs were not designed specifically to support dually diagnosed people, more than 60% of those who use them are. This program follows a normal course for recognizing at-risk groups with co-occurring conditions and enrolling them in non-traditional comprehensive programs. 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: The length of stay in the DDETC varies from six weeks to three months, depending on the severity of symptomatology, usage history, and recovery progress. Following completion of this phase of services, the client may pass across the Foundations’ housing continuum or into community-based care, as defined diagnostically and by individual presenting circumstances. To determine when and how advancement happens, an earned scheme of rights combines the achievement of treatment objectives with successful step work and milieu achievements.
  • Staffing: Staffs are supervised by resident counselors 24 hours a day, 7 days a week, with the majority of them being mentors in rehabilitation and program graduates. During business hours, a master level therapist is on-site, and each Sunday during visitation, a family therapist/educator is on-site. Via individual appointments, family counseling, and the creation of joint focused rehabilitation goals, the weekday therapist works closely with the consumer and his or her family. The weekend therapist leads a monthly education program for the consumer’s support group to discuss dual treatment dynamics, the value of medication, and create individualized reintegration strategies that emphasize both natural and structured services. NAMI support groups allow families and support networks to join. Both the nursing staff at Foundations Associates and the area mobile crisis management team are available 24 hours a day, 7 days a week for crisis calls. All customers are assessed and treated for psychopharmacologic interventions by a licensed psychiatrist as part of the group therapy/psychoeducation portion. All workers are expected to use non-confrontational, motivational interviewing methods, which are reinforced during orientation, trainings, and weekly clinical meetings.
  • Psychoeducation/Therapy: The psychoeducation/therapy program is a five-day, three-hour-per-day comprehensive, integrated dual treatment program with three regular groups, each lasting one hour, that provide psycho-education, addictions treatment, relapse prevention, therapy, and coping strategies. The central concept of psychoeducation/therapy is that all modules are designed to discuss the overlap of both conditions in a way that educates and inspires recovery hope. 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. Staff preparation focuses on non-confrontational ways of directing progress, and cognitive therapy and motivational interviewing are combined with a twelve-step dual rehabilitation intervention. A recovery team of physicians, psychologists, professional social workers, and licensed alcohol and addiction counselors provides psychological assessment, substance management, individual psychotherapy, and case management to all patients.
  • 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 for the group. Cooking, washing, and other regular tasks are carried out by residents with the aid of staff who model and teach them. 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): While the model promotes abstinence, the profile of the community served and the appreciation of different phases of rehabilitation lead to an understanding and agreement that harm reduction measures must be implemented. When a successful program participant relapses and wants to seek recovery, he or she must perform a Relapse Self Evaluation. The Relapse Self Evaluation is a protocol that facilitates introspective trigger analysis, relapse preparation, and an assessment of the relapse’s effect on the participant, community, and support systems. The member gives a public presentation of his or her evaluation and is rated by committee members based on previous motivational and commitment qualities as well as 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. In terms of evoking change and empowering collective accountability for individual members, this mechanism has had a significant effect on both the customer and the wider community. 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 rehabilitation and treatment therapy to include diagnostic education, drug education and management, relapse prevention strategies, and encouragement to participate in 12-step intervention models, especially Dual Recovery Anonymous (DRA). Both interventions explore the interconnectedness of comorbidity, and, as with the outpatient model, a mixture of psycho-educational modules and didactic therapies are used in tandem. The community service includes drug education groups and medication monitoring. The following item is on the program schedule:
  • Progressive levels of privilege: The decision to progress through the level system is based on psychological health, successful progress through the DRA rehabilitation measures, achievement of treatment goals, and a variety of other factors. The onus of change is placed on members to reinforce their obligations to themselves and the society as a whole. The following are the steps and their related responsibilities:


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.


Individual weekly therapy is also part of the Level 1 recovery process. Residents in Level 1 are encouraged to participate in weekly trips and off-campus support group meetings. 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. This stage marks the start of the consumer’s return to self-sufficiency.


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


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


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.


Attaining Level Five status means the individual has shown a strong commitment to rehabilitation and personal development. Level Five indicates that the person has regularly taken responsibility for all facets of his or her rehabilitation, is actively participating in the 12-Step recovery program on a regular basis, and exhibits integrity and accountability to themselves and others.

Consumer peer review panels, house meetings, and individual therapeutic interactions are also used to assess progress through the program. Increased psychological symptoms, relapse, increased environmental stressors, or rule violations may all result in level regression. Depending on the circumstances, both the community and the care team are involved in the majority of level change decisions.

Following the initial intensive six-eight week period of treatment, the individual’s continued participation in the Foundations’ continuum is determined by both service access and medical need. Consumers with a history of inpatient psychological and substance abuse treatment, an inability to sustain long-term sobriety without assistance, and presenting in high-risk settings are usually considered medically suitable for continued care. When resources are inaccessible or inadequate, the team focuses on improving natural and structured support structures and actively working toward reintegration readiness during the intense period of treatment’s final two weeks. Both customers who live in Foundations’ housing after intensive treatment are eligible to enroll in the Aftercare program. All other program participants are actively encouraged to engage in aftercare programs, which include big-book research, recreational events, and a focus on reintegration problems that generally impact dually diagnosed individuals.

Dual Diagnosis Enhanced Halfway House (DDEHH)

If DDEHH facilities are adequate and accessible, the resident is provided step-down housing (ASAM PPC-IIR Level III.3 half-way houses) along with a variety of nonresidential services, such as individual, community, and family counseling. 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. Clinical personnel are available 8 hours a day, with 24-hour crisis call availability from both the Foundations Associates clinical staff and the regional mobile crisis response team, as opposed to the intensive program’s 24-hour staffing schedule. When consumers arrive and leave the premises, they must check in with intensive residential program personnel for accepted passes. 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, with the primary emphasis of treatment being life skills, personal responsibility, independence, and structure. 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. Everyone in the group contributes to the creation of an individualized Therapeutic Contract that specifies community, individual, and financial/rental objectives and arrangements. For this standard of service, there is no treatment cost, 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. The Foundation’s support services are defined by an individual counseling contract that establishes group, individual, vocational, and financial priorities and agreements. The consumer is responsible for arranging community programs, psychiatric appointments, prescriptions, and other needs, and therapy sessions are limited to monthly or bimonthly encounters. Participation in aftercare is also a condition. 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. Under this arrangement, food and services are included.

Principles and Course of Treatment

SAMHSA designated Foundations Associates’ residential program as a model project for integrated treatment, and the residential services were recently named a finalist for the American Psychiatric Associations’ (APA) Gold Achievable Program Award. Case management, psychopharmacologic care, vocational counseling, psychoeducation, individual and group therapy, and 12-step therapies and interventions are all part of the residential program’s treatment plan. The program’s concept is based on seven main elements that Minkoff identifies as inherent in an integrated model of care:

1. Comorbidity is the standard, not the exception.

Foundations Associates has primarily served the high intensity SPMI/substance dependence demographic, with the majority of consumers having undergone numerous psychological and substance dependency care episodes prior to entry, based on the 4-quadrant subtyping of disorders. Pacing care according to individual needs was recognized early on as a critical component, and despite the frequent need to stabilize presenting issues such as post-withdrawal or subacute symptomatology, educational aspects that address the confluence of disorders are often included in program elements. Individual instructional and care components are brief, repeat topics regularly, and reinforce treatment of the consumer at his or her cognitive comprehension level.

Case management, rehabilitation treatments, 12-step methods (i.e., implementation of a dual recovery model), and psychopharmacologic therapy were also part of a continuum of programs designed to address comprehensive care at all service levels. Although the aim was to hire people who were skilled in integrated theories, integrated skills were quickly discovered to be in short supply. As a result, all workers are required to participate in dual recovery training, seminars, conferences, educational forums, and other activities. Similarly, in weekly meetings, team members rotate presentations on contemporary treatment approaches to comprehensive care. All workers can access information from the Dual Diagnosis Recovery Network (DDRN), a library that acts as a national archive for dual diagnosis studies.

2. 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 are geared toward emphasizing staff/client relationships in a friendly, non-punitive environment. Based on the findings of the initial assessment, a treatment plan is developed that considers both conditions to be primary, discusses dual rehabilitation, and is based on the individual’s willingness to improve. Instead of imposing conventional treatment targets, staff were instructed to create client-driven care plans. Relapses and decompensations are seen as part of the pathology of the disorders, and attempts are made to re-engage the individual as soon as possible after they occur. These episodes are used to increase user introspection about relapse and decompensation causes and symptoms, and they are explored in group meetings and individual counseling sessions.

Rather than relying on conventional approaches, attempts are being made to build services that address the needs of customers with dual diagnoses. For the complex dually diagnosed user, accommodation, for example, is often a difficult service to obtain. For the complex dually diagnosed user, accommodation, for example, is often a difficult service to obtain. Foundations mobilized consumer advocates and offered financial assistance to establish cooperative housing based on Oxford residential models because there were inadequate resources to position consumers following care in the continuum. In addition, collaborations with a number of community-based programs were established in order to target housing resources specifically for Foundations populations.

3. 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.

Person plans of care, built over the course of aggressive recovery preparation, achieve a compromise between conventional 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. In the early stages of recovery, most efforts are focused on stabilizing clinical symptomatology and controlling withdrawal symptoms and cravings. As a result, the first two weeks usually see a higher degree of case management and caretaking efforts from the staff. If the patient’s ability to guide the direction of care improves, the onus increasingly returns to the consumer. Changes to the relationship’s structure are driven by level structures, which are focused on symptom and withdrawal management as well as program success. 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. Both the client base and the counseling team assess effective advancement in house meetings.

4. When mental illness and drug abuse coexist, all conditions should be treated as primary, and integrated dual primary care should be used.

A co-primary care plan requires aggressive psychopharmacologic treatment and supervision, as well as rehabilitation principles like sober, structured housing, and DRA. 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. Instead, before moving to less restrictive treatment, consumers are assessed individually based on their success in the program, degree of consistency achieved, and other factors. Medication enforcement, attendance at 12-step sessions, and engagement in aftercare services are all closely tracked even when consumers are transferred to Dual Diagnoses Improved Halfway House levels of care. Interventions are quickly rallied in the case of relapse or decompensation, either by comprehensive clinical assessment and supervision, relapse evaluation boards, and changes to the individual’s therapeutic contract/treatment plan, or a combination of both. As one sphere decompensates, the other sphere is monitored in the same way.

5. 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.

Psychoeducation is a cornerstone of this theory, in that awareness of the disease model, coping techniques, drugs, self-monitoring, inter-relatedness of symptoms, and other issues gives hope to rehabilitation and promotes progress across phases of transition. Structured community services, house sessions, residential counseling 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. Dual rehabilitation is a central theme in all psychoeducational groups, with methodologies for maximizing quality of life being emphasized. Furthermore, a sizable portion of the workforce is made up of both people in treatment and people who have completed the program.

Similarly, the society as a whole has a big role to play in fostering change. Peer Mentors, community-based associations and councils, and a general trend of customer empowerment all play a significant role in promoting rehabilitation.

6. 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.

The procedures described in this document’s Evaluation section are used to determine the degree and extent of symptomatology, drug use history, and willingness to adjust. These dimensions guide the therapeutic approach and clinical treatment in accordance with the intervention model. Again, the population treated at Foundations Associates is mostly made up of the 10% of the population that consumes more than 70% of healthcare services. As a result, the magnitude of the conditions emphasize the importance of moving through phases of transition at the consumer’s rate. Early phases of recovery are usually focused on achieving stabilization, followed by medium phases that focus on setting personal objectives and strategies for achieving those goals, and finally late phases that 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. Consumers who are not ready for an abstinence model are not penalized, and efforts are focused on addressing the individual’s desire for change at whatever point he or she is at right now.

7. 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.

At entry, ASAM measurements are used to try to balance treatment/placement needs within the system. By integrating different protocols that assess clinical symptomatology, treatment history, and a combination of other psychiatric and drug dependence steps, domains are operationalized to guide the plan of care. Although self-report data has some limitations in terms of data collection, it does allow for a measurement of the consumer’s understanding of the need for care. The awareness serves as the framework for creating a client-centered care strategy that cannot be ignored. That perception is the basis for defining a client-driven plan of care that cannot be discounted.


Based on input from customers, practitioners, management, and external consultants, program activities have changed dramatically over the course of this project, as outlined in this study. Foundations conducted a longitudinal study of integrated care outcomes in partnership with the Tennessee Department of Mental Health and Developmental Disabilities through the Targeted Capacity Expansion grant program, with highly positive findings regarding outcomes linked to integrated intervention modalities.

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

Foundations Associates conducted a three-year longitudinal research study, conducting intake interviews with 210 consumers joining Foundations’ residential program, with 88 percent of study participants attending 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).
  • Increase the use of community-based outpatient facilities that are less restrictive (178 percent increase in outpatient visits for physical problems, 94 percent increase in outpatient psychiatric visits, and 5 percent reduction in agency-based outpatient visits related to substance abuse, accompanied by a 108 percent increase in use of self-help).


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